DR ANUSHA RAO P

PG II YR (OBG)

Traditional tests Novel predictors

bull Roll-over test

bull Isometric handgrip or cold pressor test

bull Angiotensin-II infusion

bull Midtrimester mean arterial pressure

bull Platelet angiotensin-II binding

bull Renin

bull 24-hour ambulatory blood pressure monitoring

bull Uterine artery or fetal transcranialDoppler velocimetry

bull Human chorionic gonadotropin (hCG)

bull Alpha-fetoprotein (AFP)

bull Estriol

bull Pregnancy- associated protein A (PAPP A)

bull Inhibin A

bull Activin A

bull Placental protein 13

bull Corticotropin- releasing hormone

bull Microtransferrinuria

bull N-acetyl-1113090-glucosaminidase

bull Platelet count and activation

bull Endothelial adhesion molecules

TRADITIONAL TESTS NOVEL PREDICTORS

bull Serum uric acid

bull Microalbuminuria

bull Urinary calcium or kallikrein

bull Fibronectin

bull Prostaglandin

bull Thromboxane

bull C-reactive protein

bull Cytokines

bull Endothelin

bull Neurokinin B

bull Homocysteine

bull Lipids

bull Antiphospholipid antibodies

bull Plasminogen activator-inhibitor (PAI)

NOVEL PREDICTORS

bull Leptin

bull P-selectin

bull Angiogenic factors to include placental growth factor (PIGF) vascular endothelial growth factor (VEGF) fms-like tyrosine kinase receptor-1 (sFLT-1) Endoglin

bull Antithrombin-III(AT-3)

bull Atrial natriuretic peptide (ANP)

bull 11130902-microglobulin

bull Genetic markers

bull Free fetal DNA

bull Serum proteonomic markers

The ideal biochemical marker for PE should

exhibit the following characteristics

0 1)Play a central role in the pathogenesis and be specific for the condition

0 2) Appear early or before the clinical manifestations Placental factors that can be detected early in pregnancy are likely to be good biochemical markers for PE prediction

0However placental disorders can cause IUGR without PE and vice versa which makes the clinical evaluation of new markers particularly hard

0 3) Be easy and cheap to measure in maternal blood or urine Few of the described factors are easy to measure most of them require advanced laboratory system

0 4) Show a high sensitivity and specificity A small number of the described biochemical markers fulfill this requirement and strategies to use them in combination with other markers andor with PI measurements and other clinical parameters are being investigated

0 5) Correlate with the severity of the condition As the disease progresses several organ systems are affected which causes the number of factors to increase throughout pregnancy A good candidate marker ought to appear early in pregnancy andcontinue to rise as the disease progresses

0 6) Be non-detected or expressed at very low levels in normal pregnancies Again a placental factor is favored since the clinical symptoms disappear after removal of the placenta

Angiotensin II sensitivity0 Preeclamptic women show an elevated pressor response

to vasopressin

0Although the performance of the test had a 77sensitivity and 95 specificity in 1973

0The largest most recent study of 494 healthy nulliparous women found a disappointing sensitivity of 22 with a specificity of 85 for prediction of pregnancy induced hypertensive disorders

0The disappointing results of recent studies raises doubts about usefulness as a continuing test

0Urine albumin excretion rate was the best predictive value for preeclampsia in hypertensive patient when blood for fibronectin anthithrombin3alpha 1 microglobulin U-N acetyl-beta-glucosominidase uric acid and albumin excretion rate was studied in 68 non pregnancy induced hypertensive and 40 chronic hypertensive positive predictive value and specificity being 875 and 989 respectively

0Elevated serum uric acid levels were associated with clinical severity of preeclampsia and perinatal outcomes Despite a good amount of studies not of all studies suggest that the serum uric acid levels may begin to rise before the onset of hypertension and proteinuria

0 Hyperuricaemia an early sign of renal involvement in preeclampsia is the result of reduced renal clearance due to altered tubular processing of uric acid preceding glomerular affliction which will cause albminuria

0However results from recent studies show that despite its long history of use the discriminatory value of serum uric acid as a predictor of preeclampsia remains to be proven

0Rodriques and Susuki showed that in women with a low levels of calciumcreatinine ratio and high microalbuminuria 84 developed PE

0Microproteinuria levels above 375mgl may be significant and thus could be utilized as a screening test for the early detection of a woman at risk of developing preeclampsia

0However there is no diagnostic value of microalbuminuria and the calciumcreatinine ratio when used alone

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Traditional tests Novel predictors

bull Roll-over test

bull Isometric handgrip or cold pressor test

bull Angiotensin-II infusion

bull Midtrimester mean arterial pressure

bull Platelet angiotensin-II binding

bull Renin

bull 24-hour ambulatory blood pressure monitoring

bull Uterine artery or fetal transcranialDoppler velocimetry

bull Human chorionic gonadotropin (hCG)

bull Alpha-fetoprotein (AFP)

bull Estriol

bull Pregnancy- associated protein A (PAPP A)

bull Inhibin A

bull Activin A

bull Placental protein 13

bull Corticotropin- releasing hormone

bull Microtransferrinuria

bull N-acetyl-1113090-glucosaminidase

bull Platelet count and activation

bull Endothelial adhesion molecules

TRADITIONAL TESTS NOVEL PREDICTORS

bull Serum uric acid

bull Microalbuminuria

bull Urinary calcium or kallikrein

bull Fibronectin

bull Prostaglandin

bull Thromboxane

bull C-reactive protein

bull Cytokines

bull Endothelin

bull Neurokinin B

bull Homocysteine

bull Lipids

bull Antiphospholipid antibodies

bull Plasminogen activator-inhibitor (PAI)

NOVEL PREDICTORS

bull Leptin

bull P-selectin

bull Angiogenic factors to include placental growth factor (PIGF) vascular endothelial growth factor (VEGF) fms-like tyrosine kinase receptor-1 (sFLT-1) Endoglin

bull Antithrombin-III(AT-3)

bull Atrial natriuretic peptide (ANP)

bull 11130902-microglobulin

bull Genetic markers

bull Free fetal DNA

bull Serum proteonomic markers

The ideal biochemical marker for PE should

exhibit the following characteristics

0 1)Play a central role in the pathogenesis and be specific for the condition

0 2) Appear early or before the clinical manifestations Placental factors that can be detected early in pregnancy are likely to be good biochemical markers for PE prediction

0However placental disorders can cause IUGR without PE and vice versa which makes the clinical evaluation of new markers particularly hard

0 3) Be easy and cheap to measure in maternal blood or urine Few of the described factors are easy to measure most of them require advanced laboratory system

0 4) Show a high sensitivity and specificity A small number of the described biochemical markers fulfill this requirement and strategies to use them in combination with other markers andor with PI measurements and other clinical parameters are being investigated

0 5) Correlate with the severity of the condition As the disease progresses several organ systems are affected which causes the number of factors to increase throughout pregnancy A good candidate marker ought to appear early in pregnancy andcontinue to rise as the disease progresses

0 6) Be non-detected or expressed at very low levels in normal pregnancies Again a placental factor is favored since the clinical symptoms disappear after removal of the placenta

Angiotensin II sensitivity0 Preeclamptic women show an elevated pressor response

to vasopressin

0Although the performance of the test had a 77sensitivity and 95 specificity in 1973

0The largest most recent study of 494 healthy nulliparous women found a disappointing sensitivity of 22 with a specificity of 85 for prediction of pregnancy induced hypertensive disorders

0The disappointing results of recent studies raises doubts about usefulness as a continuing test

0Urine albumin excretion rate was the best predictive value for preeclampsia in hypertensive patient when blood for fibronectin anthithrombin3alpha 1 microglobulin U-N acetyl-beta-glucosominidase uric acid and albumin excretion rate was studied in 68 non pregnancy induced hypertensive and 40 chronic hypertensive positive predictive value and specificity being 875 and 989 respectively

0Elevated serum uric acid levels were associated with clinical severity of preeclampsia and perinatal outcomes Despite a good amount of studies not of all studies suggest that the serum uric acid levels may begin to rise before the onset of hypertension and proteinuria

0 Hyperuricaemia an early sign of renal involvement in preeclampsia is the result of reduced renal clearance due to altered tubular processing of uric acid preceding glomerular affliction which will cause albminuria

0However results from recent studies show that despite its long history of use the discriminatory value of serum uric acid as a predictor of preeclampsia remains to be proven

0Rodriques and Susuki showed that in women with a low levels of calciumcreatinine ratio and high microalbuminuria 84 developed PE

0Microproteinuria levels above 375mgl may be significant and thus could be utilized as a screening test for the early detection of a woman at risk of developing preeclampsia

0However there is no diagnostic value of microalbuminuria and the calciumcreatinine ratio when used alone

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

TRADITIONAL TESTS NOVEL PREDICTORS

bull Serum uric acid

bull Microalbuminuria

bull Urinary calcium or kallikrein

bull Fibronectin

bull Prostaglandin

bull Thromboxane

bull C-reactive protein

bull Cytokines

bull Endothelin

bull Neurokinin B

bull Homocysteine

bull Lipids

bull Antiphospholipid antibodies

bull Plasminogen activator-inhibitor (PAI)

NOVEL PREDICTORS

bull Leptin

bull P-selectin

bull Angiogenic factors to include placental growth factor (PIGF) vascular endothelial growth factor (VEGF) fms-like tyrosine kinase receptor-1 (sFLT-1) Endoglin

bull Antithrombin-III(AT-3)

bull Atrial natriuretic peptide (ANP)

bull 11130902-microglobulin

bull Genetic markers

bull Free fetal DNA

bull Serum proteonomic markers

The ideal biochemical marker for PE should

exhibit the following characteristics

0 1)Play a central role in the pathogenesis and be specific for the condition

0 2) Appear early or before the clinical manifestations Placental factors that can be detected early in pregnancy are likely to be good biochemical markers for PE prediction

0However placental disorders can cause IUGR without PE and vice versa which makes the clinical evaluation of new markers particularly hard

0 3) Be easy and cheap to measure in maternal blood or urine Few of the described factors are easy to measure most of them require advanced laboratory system

0 4) Show a high sensitivity and specificity A small number of the described biochemical markers fulfill this requirement and strategies to use them in combination with other markers andor with PI measurements and other clinical parameters are being investigated

0 5) Correlate with the severity of the condition As the disease progresses several organ systems are affected which causes the number of factors to increase throughout pregnancy A good candidate marker ought to appear early in pregnancy andcontinue to rise as the disease progresses

0 6) Be non-detected or expressed at very low levels in normal pregnancies Again a placental factor is favored since the clinical symptoms disappear after removal of the placenta

Angiotensin II sensitivity0 Preeclamptic women show an elevated pressor response

to vasopressin

0Although the performance of the test had a 77sensitivity and 95 specificity in 1973

0The largest most recent study of 494 healthy nulliparous women found a disappointing sensitivity of 22 with a specificity of 85 for prediction of pregnancy induced hypertensive disorders

0The disappointing results of recent studies raises doubts about usefulness as a continuing test

0Urine albumin excretion rate was the best predictive value for preeclampsia in hypertensive patient when blood for fibronectin anthithrombin3alpha 1 microglobulin U-N acetyl-beta-glucosominidase uric acid and albumin excretion rate was studied in 68 non pregnancy induced hypertensive and 40 chronic hypertensive positive predictive value and specificity being 875 and 989 respectively

0Elevated serum uric acid levels were associated with clinical severity of preeclampsia and perinatal outcomes Despite a good amount of studies not of all studies suggest that the serum uric acid levels may begin to rise before the onset of hypertension and proteinuria

0 Hyperuricaemia an early sign of renal involvement in preeclampsia is the result of reduced renal clearance due to altered tubular processing of uric acid preceding glomerular affliction which will cause albminuria

0However results from recent studies show that despite its long history of use the discriminatory value of serum uric acid as a predictor of preeclampsia remains to be proven

0Rodriques and Susuki showed that in women with a low levels of calciumcreatinine ratio and high microalbuminuria 84 developed PE

0Microproteinuria levels above 375mgl may be significant and thus could be utilized as a screening test for the early detection of a woman at risk of developing preeclampsia

0However there is no diagnostic value of microalbuminuria and the calciumcreatinine ratio when used alone

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

NOVEL PREDICTORS

bull Leptin

bull P-selectin

bull Angiogenic factors to include placental growth factor (PIGF) vascular endothelial growth factor (VEGF) fms-like tyrosine kinase receptor-1 (sFLT-1) Endoglin

bull Antithrombin-III(AT-3)

bull Atrial natriuretic peptide (ANP)

bull 11130902-microglobulin

bull Genetic markers

bull Free fetal DNA

bull Serum proteonomic markers

The ideal biochemical marker for PE should

exhibit the following characteristics

0 1)Play a central role in the pathogenesis and be specific for the condition

0 2) Appear early or before the clinical manifestations Placental factors that can be detected early in pregnancy are likely to be good biochemical markers for PE prediction

0However placental disorders can cause IUGR without PE and vice versa which makes the clinical evaluation of new markers particularly hard

0 3) Be easy and cheap to measure in maternal blood or urine Few of the described factors are easy to measure most of them require advanced laboratory system

0 4) Show a high sensitivity and specificity A small number of the described biochemical markers fulfill this requirement and strategies to use them in combination with other markers andor with PI measurements and other clinical parameters are being investigated

0 5) Correlate with the severity of the condition As the disease progresses several organ systems are affected which causes the number of factors to increase throughout pregnancy A good candidate marker ought to appear early in pregnancy andcontinue to rise as the disease progresses

0 6) Be non-detected or expressed at very low levels in normal pregnancies Again a placental factor is favored since the clinical symptoms disappear after removal of the placenta

Angiotensin II sensitivity0 Preeclamptic women show an elevated pressor response

to vasopressin

0Although the performance of the test had a 77sensitivity and 95 specificity in 1973

0The largest most recent study of 494 healthy nulliparous women found a disappointing sensitivity of 22 with a specificity of 85 for prediction of pregnancy induced hypertensive disorders

0The disappointing results of recent studies raises doubts about usefulness as a continuing test

0Urine albumin excretion rate was the best predictive value for preeclampsia in hypertensive patient when blood for fibronectin anthithrombin3alpha 1 microglobulin U-N acetyl-beta-glucosominidase uric acid and albumin excretion rate was studied in 68 non pregnancy induced hypertensive and 40 chronic hypertensive positive predictive value and specificity being 875 and 989 respectively

0Elevated serum uric acid levels were associated with clinical severity of preeclampsia and perinatal outcomes Despite a good amount of studies not of all studies suggest that the serum uric acid levels may begin to rise before the onset of hypertension and proteinuria

0 Hyperuricaemia an early sign of renal involvement in preeclampsia is the result of reduced renal clearance due to altered tubular processing of uric acid preceding glomerular affliction which will cause albminuria

0However results from recent studies show that despite its long history of use the discriminatory value of serum uric acid as a predictor of preeclampsia remains to be proven

0Rodriques and Susuki showed that in women with a low levels of calciumcreatinine ratio and high microalbuminuria 84 developed PE

0Microproteinuria levels above 375mgl may be significant and thus could be utilized as a screening test for the early detection of a woman at risk of developing preeclampsia

0However there is no diagnostic value of microalbuminuria and the calciumcreatinine ratio when used alone

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

The ideal biochemical marker for PE should

exhibit the following characteristics

0 1)Play a central role in the pathogenesis and be specific for the condition

0 2) Appear early or before the clinical manifestations Placental factors that can be detected early in pregnancy are likely to be good biochemical markers for PE prediction

0However placental disorders can cause IUGR without PE and vice versa which makes the clinical evaluation of new markers particularly hard

0 3) Be easy and cheap to measure in maternal blood or urine Few of the described factors are easy to measure most of them require advanced laboratory system

0 4) Show a high sensitivity and specificity A small number of the described biochemical markers fulfill this requirement and strategies to use them in combination with other markers andor with PI measurements and other clinical parameters are being investigated

0 5) Correlate with the severity of the condition As the disease progresses several organ systems are affected which causes the number of factors to increase throughout pregnancy A good candidate marker ought to appear early in pregnancy andcontinue to rise as the disease progresses

0 6) Be non-detected or expressed at very low levels in normal pregnancies Again a placental factor is favored since the clinical symptoms disappear after removal of the placenta

Angiotensin II sensitivity0 Preeclamptic women show an elevated pressor response

to vasopressin

0Although the performance of the test had a 77sensitivity and 95 specificity in 1973

0The largest most recent study of 494 healthy nulliparous women found a disappointing sensitivity of 22 with a specificity of 85 for prediction of pregnancy induced hypertensive disorders

0The disappointing results of recent studies raises doubts about usefulness as a continuing test

0Urine albumin excretion rate was the best predictive value for preeclampsia in hypertensive patient when blood for fibronectin anthithrombin3alpha 1 microglobulin U-N acetyl-beta-glucosominidase uric acid and albumin excretion rate was studied in 68 non pregnancy induced hypertensive and 40 chronic hypertensive positive predictive value and specificity being 875 and 989 respectively

0Elevated serum uric acid levels were associated with clinical severity of preeclampsia and perinatal outcomes Despite a good amount of studies not of all studies suggest that the serum uric acid levels may begin to rise before the onset of hypertension and proteinuria

0 Hyperuricaemia an early sign of renal involvement in preeclampsia is the result of reduced renal clearance due to altered tubular processing of uric acid preceding glomerular affliction which will cause albminuria

0However results from recent studies show that despite its long history of use the discriminatory value of serum uric acid as a predictor of preeclampsia remains to be proven

0Rodriques and Susuki showed that in women with a low levels of calciumcreatinine ratio and high microalbuminuria 84 developed PE

0Microproteinuria levels above 375mgl may be significant and thus could be utilized as a screening test for the early detection of a woman at risk of developing preeclampsia

0However there is no diagnostic value of microalbuminuria and the calciumcreatinine ratio when used alone

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 3) Be easy and cheap to measure in maternal blood or urine Few of the described factors are easy to measure most of them require advanced laboratory system

0 4) Show a high sensitivity and specificity A small number of the described biochemical markers fulfill this requirement and strategies to use them in combination with other markers andor with PI measurements and other clinical parameters are being investigated

0 5) Correlate with the severity of the condition As the disease progresses several organ systems are affected which causes the number of factors to increase throughout pregnancy A good candidate marker ought to appear early in pregnancy andcontinue to rise as the disease progresses

0 6) Be non-detected or expressed at very low levels in normal pregnancies Again a placental factor is favored since the clinical symptoms disappear after removal of the placenta

Angiotensin II sensitivity0 Preeclamptic women show an elevated pressor response

to vasopressin

0Although the performance of the test had a 77sensitivity and 95 specificity in 1973

0The largest most recent study of 494 healthy nulliparous women found a disappointing sensitivity of 22 with a specificity of 85 for prediction of pregnancy induced hypertensive disorders

0The disappointing results of recent studies raises doubts about usefulness as a continuing test

0Urine albumin excretion rate was the best predictive value for preeclampsia in hypertensive patient when blood for fibronectin anthithrombin3alpha 1 microglobulin U-N acetyl-beta-glucosominidase uric acid and albumin excretion rate was studied in 68 non pregnancy induced hypertensive and 40 chronic hypertensive positive predictive value and specificity being 875 and 989 respectively

0Elevated serum uric acid levels were associated with clinical severity of preeclampsia and perinatal outcomes Despite a good amount of studies not of all studies suggest that the serum uric acid levels may begin to rise before the onset of hypertension and proteinuria

0 Hyperuricaemia an early sign of renal involvement in preeclampsia is the result of reduced renal clearance due to altered tubular processing of uric acid preceding glomerular affliction which will cause albminuria

0However results from recent studies show that despite its long history of use the discriminatory value of serum uric acid as a predictor of preeclampsia remains to be proven

0Rodriques and Susuki showed that in women with a low levels of calciumcreatinine ratio and high microalbuminuria 84 developed PE

0Microproteinuria levels above 375mgl may be significant and thus could be utilized as a screening test for the early detection of a woman at risk of developing preeclampsia

0However there is no diagnostic value of microalbuminuria and the calciumcreatinine ratio when used alone

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Angiotensin II sensitivity0 Preeclamptic women show an elevated pressor response

to vasopressin

0Although the performance of the test had a 77sensitivity and 95 specificity in 1973

0The largest most recent study of 494 healthy nulliparous women found a disappointing sensitivity of 22 with a specificity of 85 for prediction of pregnancy induced hypertensive disorders

0The disappointing results of recent studies raises doubts about usefulness as a continuing test

0Urine albumin excretion rate was the best predictive value for preeclampsia in hypertensive patient when blood for fibronectin anthithrombin3alpha 1 microglobulin U-N acetyl-beta-glucosominidase uric acid and albumin excretion rate was studied in 68 non pregnancy induced hypertensive and 40 chronic hypertensive positive predictive value and specificity being 875 and 989 respectively

0Elevated serum uric acid levels were associated with clinical severity of preeclampsia and perinatal outcomes Despite a good amount of studies not of all studies suggest that the serum uric acid levels may begin to rise before the onset of hypertension and proteinuria

0 Hyperuricaemia an early sign of renal involvement in preeclampsia is the result of reduced renal clearance due to altered tubular processing of uric acid preceding glomerular affliction which will cause albminuria

0However results from recent studies show that despite its long history of use the discriminatory value of serum uric acid as a predictor of preeclampsia remains to be proven

0Rodriques and Susuki showed that in women with a low levels of calciumcreatinine ratio and high microalbuminuria 84 developed PE

0Microproteinuria levels above 375mgl may be significant and thus could be utilized as a screening test for the early detection of a woman at risk of developing preeclampsia

0However there is no diagnostic value of microalbuminuria and the calciumcreatinine ratio when used alone

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Urine albumin excretion rate was the best predictive value for preeclampsia in hypertensive patient when blood for fibronectin anthithrombin3alpha 1 microglobulin U-N acetyl-beta-glucosominidase uric acid and albumin excretion rate was studied in 68 non pregnancy induced hypertensive and 40 chronic hypertensive positive predictive value and specificity being 875 and 989 respectively

0Elevated serum uric acid levels were associated with clinical severity of preeclampsia and perinatal outcomes Despite a good amount of studies not of all studies suggest that the serum uric acid levels may begin to rise before the onset of hypertension and proteinuria

0 Hyperuricaemia an early sign of renal involvement in preeclampsia is the result of reduced renal clearance due to altered tubular processing of uric acid preceding glomerular affliction which will cause albminuria

0However results from recent studies show that despite its long history of use the discriminatory value of serum uric acid as a predictor of preeclampsia remains to be proven

0Rodriques and Susuki showed that in women with a low levels of calciumcreatinine ratio and high microalbuminuria 84 developed PE

0Microproteinuria levels above 375mgl may be significant and thus could be utilized as a screening test for the early detection of a woman at risk of developing preeclampsia

0However there is no diagnostic value of microalbuminuria and the calciumcreatinine ratio when used alone

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Elevated serum uric acid levels were associated with clinical severity of preeclampsia and perinatal outcomes Despite a good amount of studies not of all studies suggest that the serum uric acid levels may begin to rise before the onset of hypertension and proteinuria

0 Hyperuricaemia an early sign of renal involvement in preeclampsia is the result of reduced renal clearance due to altered tubular processing of uric acid preceding glomerular affliction which will cause albminuria

0However results from recent studies show that despite its long history of use the discriminatory value of serum uric acid as a predictor of preeclampsia remains to be proven

0Rodriques and Susuki showed that in women with a low levels of calciumcreatinine ratio and high microalbuminuria 84 developed PE

0Microproteinuria levels above 375mgl may be significant and thus could be utilized as a screening test for the early detection of a woman at risk of developing preeclampsia

0However there is no diagnostic value of microalbuminuria and the calciumcreatinine ratio when used alone

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Rodriques and Susuki showed that in women with a low levels of calciumcreatinine ratio and high microalbuminuria 84 developed PE

0Microproteinuria levels above 375mgl may be significant and thus could be utilized as a screening test for the early detection of a woman at risk of developing preeclampsia

0However there is no diagnostic value of microalbuminuria and the calciumcreatinine ratio when used alone

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0When clinical utility of urinary soluble endoglin was

compared with soluble fms-like tyrosine kinase 1 to placental growth factor (PIGF)ratio soluble endoglin levels were significantly raised in preterm preeclampsia

0However urinary endoglin has limitations to determine the severity of preeclampsia and to differentiate between preeclampsia and chronic hypertension

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Women with preeclampsia appear to present a unique urine proteomic fingerprint composed of SERPINA1 and albumin

fragments that predicts preeclampsia in need of mandated delivery with highest accuracy

0 This characteristic proteomic profile also has the ability to distinguish preeclampsia from other hypertensive or proteinuricdisorders in pregnancy

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Urine levels of inhibin A showed the greatest discrimination

between severe preeclampsia and pregnant control women when there was cut off of 45pgmg for urine creatinine

0 Women with greater than 90pgmg urinary creatinine had a 17 fold relative risk of a clinically indicated delivery due to preeclampsia

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Measurement of urinary kallikrein(IUK)to creatinine ratio(IUKcr) between 16-20 weeks of

gestation for determining the risk of developing subsequent preeclampsia with a sensitivity and specificity comparable to those reports as ascertained by other investigators using the well recognized but less practical angiotensin II sensitivity test

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Urinary microtransferrinuria levels in

pregnant women who subsequently developed preeclampsia and eclampsia where significantly higher than those pregnant women who remained normotensive

0Microtranferrinuria as a predictor for preeclampsia had a sensitivity 935specificity 65positive predictive value of 83 and a negative predictive value of 984

0Microtranferrinuria is potentially a more sensitive predictor of preeclampsia than microalbuminuria

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0The urinary excretion of N-acetyl-beta-glucosaminidine a lysosomal enzyme of the renal

tubular cells was increased in normal pregnant women and in woman with transient hypertension when compared to non pregnant healthy controls

0 In preeclampsia women the increase was much higher than corresponding to their gestational age

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Serum InhibinndashA was determined as a more sensitive

marker for the prediction of preeclampsia than hCG

0Addition of hCG data to inhibin did not improve the screening efficiency for preeclampsia suggesting that inhibin-A and hCG are markers of the same underlying pathological process

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Midtrimester beta-hCG levels alone correlated significantly

with the severity of preeclampsia

0However the combination of MShCG levels body mass index(BMI)parity and age as a predictive test for preeclampsia was far superior to MShCG alone

0This multi-factorial model could identify preeclampsia with a sensitivity of 70 and a specificity of 71

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Although the plasma TNF-alpha levels were higher

in preeclamptics compared with normotensivesthe levels cannot be used in the first second trimester as a specific marker

0However they may be useful in the early third trimester

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 Serum thrombomodulin antigen levels were

measured in patients with preeclampsia gestational hypertension and chronic hypertension

0 Levels were higher in preeclampsia than those with gestational hypertension or chronic hypertension

0Thrombomodulin may serve as a clinical marker to differentiate preeclampsia from other disorders of pregnancy

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 low levels of SHBG in the first half of pregnancy were reported

as a promising early risk marker of the later development of preeclampsia

0However as compared to normotensives controls preeclampticwomen exhibited no statically significant differences in the median levels of total testerone free androgen index sex hormone binding globulin or dehydroepiandrosterone

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 Serum levels of collagen synthesis procollagen I carboxy-

terminal peptide (PICP) and procollagen111 amino-terminal peptide (PIIIP) in patients with preeclampsia and controls

0The markers were mildly elevated in preeclampsia but unlikely to be useful in the prediction of preeclampsia

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Mid-trimester amniotic fluid cytokinase may

reflect the maternal immune system in the maternal fetal interface and thus be predictive of preeclampsia

0 concentrations of interleukin (IL)-6810111215 tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta in the amniotic fluid at 14-16 weeks gestation from women with normal pregnancies and from those who subsequently developed severe preeclampsiaare being studied

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Proteomics alterations in pre-eclampsia suggest that

possible cellular battle against mitochondria-originated oxidative stress test resulting in recovery or apoptosis

0The over expression of chaperonin 60 GST VDAC Erp29 and cathespin D in pre-eclampsia makes it a ideal marker of predicting preeclampsia

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 Serum CA125 variability

0 Lipoprotein a-Lp(a)

0 Coagulation Factors and Platelets

0 Serum Oestriol

0Maternal serum alpha fetoprotein (MSAFP)

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Pregnancy ndash associated protein A (PAPP-A) is a

glycoprotein synthesized in the placenta and the maternal plasma concentration increases through out pregnancy

0 PAPP-A has been used in combination with b-human chorionic gonadotropin (b-hCG) and nuchal translucency thickness to screen for trisomy 21 13 and 18 at 11 to 13 weeks of gestation

0 In fetuses with normal chromosomes decreased levels of PAPP-A in the 1st trimester have been associated with increased risk for PE IUGR fetuses small for gestational age (SGA) and preterm delivery

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 PAPP-A has been evaluated as a predictive and diagnostic biochemical marker for PE but the screening performance when used as a single biochemical marker is only about 10 to 20

0 Combined with Doppler ultrasound PAPP-A is a powerful predictive biochemical marker of PE with prediction rates of 70 at false positive rates of 5

0 At term plasma PAPP-A concentrations have been shown to increase in pregnancies complicated by PE and HELLP but its concentration is still not predictive

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 Recent reports suggest that free extracellular fetal hemoglobin(HbF) is involved in the pathogenesis of PE

0 Furthermore the heme and radical scavenger a1-microglobulin (A1M) is involved in the physiological defence against HbF

0 Their concentrations in maternal serum or plasma can be used as early predictive biochemical markers

0 Increased mRNA levels of HbF in the placental tissue and

free HbF protein in the placental vascular lumen were

described in women with PE

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Placental protein 13 (PP13) is a member of the

galectin family and is produced by the placental trophoblast cells and is associated with normal placentation

0 In normal pregnancies serum levels of PP13 slowly rise with gestational age

0 Several studies have shown lowered serum levels in the first trimester in pregnancies that subsequently developed PE

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0When combining serum screening with Doppler ultrasound pulsatility index (PI) the prediction rate increased to 71 at a false positive rate of 10

0 PP13 was concluded to be a reasonable biochemical marker for early onset and preterm PE but a weak marker for PE at term

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Elevated levels of Soluble fms-like tyrosine kinase 1 (sFlt-1) occur before the clinical symptoms The levels correlate with the time of onset of clinically manifest PE and partly with disease severity

0Early-onset PE exhibits higher levels of sFlt-1

0 sFlt-1 increase is observed approximately 5 weeks before onset of PE

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Soluble Endoglin (sEng) truncated form of endoglin (CD105) a cell receptor for transforming growth factor-beta (TGF-β) has been localized to both placental syncytiotrophoblasts and endothelial cells

0 Soluble endoglin is a second trimester marker for preeclampsia

0 Circulating sFlt-1 and sEng may synergize and contribute to PE via different but additive mechanism probably by inhibition of NO production causing endothelial dysfunction

0 Circulating soluble endoglin levels were shown to increase 2-3 months before the onset of severe early-onset preeclampsia

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0As a first trimester screening marker soluble endoglin (s-Eng) shows conflicting results

0 Used in combination with Doppler ultrasound (PI) and PlGF the prediction rate for early onset PE was 778 at a false positive rate of 5

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

sFlt-1 levels are stable during early amp mid gestation

then increase significantly during late stages

Angiogenic Markers In Healthy Pregnancy

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Changes in circulating angiogenic factors from first to second trimester

as predictors of PE

0 Low or no increase in serum concentration of free PlGF VEGF amp high concentration of sFlt-1 a strong predictor of early PE

0 Low increase in PlGF amp low increase in sFlt are associated with 10 fold higher risk of pre term PE

0 Low increase in PlGF in early pregnancy independent of change in sFlt-1 is associated with high risk ndashPE

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Mean sFlt-1 concentration and gestational age

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Mean PIGF concentration and gestational age

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Latest results sFLT-1 free VEGF not usefulin the 1st trimester screening

Measurement of free-VEGF andsFlt-1 in maternal blood at 11 to 13 weeks ofgestation is not useful in the prediction ofpregnancies destined to develop PE

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

sFlt-1 to PlGF Ratio as a Predictor for PE

0 It is an index of antiangiogenic activity that reflects changes in the balance between sFlt-1 amp PlGF obviously seen in PE

0 Women with PE have reduced uteroplacental blood flow

0 Several studies have shown the predictive power of PlGFsFlt-1 ratio from the second trimester

0 The prediction rate is about 89

0 The transcription factor hypoxia ndashinducible factor 1 (HIF 1 alpha) regulates VEGF amp Flt-1gene transcription

0 HIF-1 2 are elevated in pre eclamptic placenta

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Angiogenic Factors Prediction of PE In High Risk Women

0High risk women ndashPrevious HO PE Multiple gestation pre gestational DM Chronic hypertension chronic kidney disease obesity amp adolescent age

0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with advancing gestation may be predictive of PE

0Mean serum sFlt-1 sFlt-1PlGF were higher with early onset PE (lt 34 weeks)

0Above ratio at 22-26 weeks was highly predictive of early onset PE

0A 2 tiered screening approach may be a useful tool for prediction

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Twin pregnancies are associated with 2-3 fold increased risk for PE

0 Circulating levels of sFlt-1 PlGF ratio were twice as high as in singleton

0But not accompanied by any change in levels of sFlt-1 mRNA amp HIF ndash alpha protein in the twin placentas but were correlated with placental weight

0Trisomy 13 a risk factor as gene for sFlt-1 is located on that chromosome

0 Smokers have low sFlt-1levels amp less Incidence of PE

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 Leptin the product of the ob gene is a hormone that is produced mostly in adipose cells

0 It is also produced in the placenta and may affect a number of processes in this organ including angiogenesis growth and immunomodulation It has been suggested that leptin may be involved in the pathogenesis of preeclampsia

0 Many studies have reported high maternal leptin concentrations in the second trimester of pregnancy in women with preeclampsia

0 However serum leptin concentrations in the early part of pregnancy did not differ between the preeclamptic and non-preeclamptic women

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Insulin-like growth factor-1 (IGF-1) is a hormone that

may be involved in both normal and abnormal fetal growth

0This hormone stimulates the renal and placental 125-dihydroxyvitamin D synthesis

0 It has been found that during preeclampsia the maternal IGF concentrations are lower compared with those in normal pregnancy

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 It has been shown that there is a 5-fold increase in circulating

fetal DNA concentrations in the maternal plasma with established preeclampsia compared with control

pregnant subjects

0This increase could be secondary to an increased entry of fetal cells such as trophoblasts and erythroblasts into the maternal circulation or the fetal DNA could liberate directly from dying cells in the placenta and a confirmation to this comes from the demonstration of widespread apoptosis in cytotrophoblastsobtained from the placental beds of preeclamptic pregnancies

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Neutrophil gelatinase associated lipocalin(NGAL) also known as lipocalin-2 siderocalin uterocalin and 24p3 is a 25 kDa secreted protein that belongs to the family of lipocalins

0NGAL is considered as the best and the earliest markers of acute kidney damage where its presence can be detected in the urine within 2 hrs following the renal insult

0A recent study demonstrated that the serum levels of NGAL increased at the end of the second trimester in women who subsequently developed pre-eclampsia compared to the control group

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Auto-antibodies directed against the angiotensin-II type-1 receptor (AT1-AA) were detected in the blood from women with PE The authors reporting this discovery provocatively suggested that plasma exchange could be a way of prevention

0Undoubtedly these questions will have to be addressed before the clearance of AT1-AA can be considered as a therapeutic option As a marker AT1-AA appears to be less efficient than sFlt-1

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many features of preeclampsiaAT1-AAs from preeclamptic patients activate angiotensinreceptors (AT1R) on the surface of many cell types and may be responsible for many features of this serious pregnancy disorder We have shown that antibody-induced receptor activation results in the mobilization of intracellular calcium and the activation of many genes We propose that AT1-AAs activate AT1 receptors by promoting receptor homodimerization ROS reactive oxygen species SMC smooth muscle cells EC endothelial cells

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Cystatin C is a protease inhibitor widely used by clinicians

as a sensitive marker for renal function and for estimation of glomerular filtration rate

0 The maternal plasma level of cystatin C is increased in women with PE and studies have demonstrated that the level of cystatin C is a reliable diagnostic marker for PE in the 1st

trimester

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Genes for pre-eclampsia discovered

0 The US researchers from the Washington University School of Medicine in St Louis analyzed DNA from over 300 pregnant women 40 normal amp remaining 250 were women who were being monitored for other health complications Forty of these also went on to develop pre-eclampsia

0 DNA analysis revealed a few genetic errors shared by five of the 60 otherwise healthy women and seven of the 40 higher-risk pregnancy women who developed pre-eclampsia

0 The genes on which the errors were identified (MCP factor I and factor H) play a role in regulating immune response and the researchers believe this could explain their possible link to pre-eclampsia

0 Scientists have suspected that problems with the immune system provoke many cases of pre-eclampsia because women with lupus and certain other autoimmune diseases - like 250 of the women in the study - have an increased risk of the disorder

0 At best genes like these might identify 10-15 of pre-eclampsia so its relative importance may not be sensational But it may allow us to study new treatments to prevent or delay the onset of pre-eclampsia and to know which women need closer surveillance

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Use of Doppler

Pre-eclampsia screening in the first trimester of pregnancy

0The combined use of transvaginal ultrasonography with the pulse-color Doppler technique allows the study of the uterine and umbilical circulation during the first trimester

0 Color Doppler imaging helps to identify the changes in uterine artery blood flow at 6-9 weeks of gestation

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Doppler studies of brachial artery reactivity in women who have had pre-eclampsia show abnormal endothelial dependent flow-mediated arterial dilation three years after pregnancy

0A relation between high resistance uterine artery waveforms in the second half of pregnancy and pre-eclampsia has already been established and persistent notching of the uterine artery Doppler waveform has shown promise as a screening test at 20 and 24 weeks

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 Increased impedance to flow in the uterine arteries in both high-risk and low-risk pregnancies is associated with increased risk of development of pre-eclampsiaand intrauterine growth restriction

0Women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 Increased impedance to flow in the uterine arteries in pregnancy attending for routine antenatal care identifies about 50 of those that subsequently develop pre-eclampsia

0Abnormal Doppler is better in predicting severe rather than mild pre-eclampsia The sensitivity for severe pre-eclampsia is about 75

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

conclusion0 Screening for Down syndrome in the first trimester is a good example where a

combination of ultrasound scanning and biochemical markers are used

Eg It would be important to assess whether the measurement of other indices combined with inhibin A can produce a test with greater sensitivity for preeclampsia as occurs with triple or quadruple blood tests for Downs syndrome This would open up new possibilities for the testing of preventive methods and the trials of treatments for this pregnancy-specific syndrome

0 Potential first trimester biochemical markers are PAPP-A HbF and A1M

0 Both HbF and A1M play a role in the pathophysiology of PE

0 The biochemical markers appear as early as 10 weeks of gestation Furthermore they can be measured with basic ELISA techniques and show a high prediction rate at a low false positive level

0 Maternal plasma concentrations of free HbF have also been shown to correlate well with severity ie blood pressure in term PE pregnancies

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0Angiogenic and anti-angiogenic factors are also very promising biochemical markers

0 Although the combination sFlt-1PlGF might not be useful in the first trimester they are definitely well evaluated in the second trimester

0 Alterations of sFlt-1 and PlGF about 6 weeks before the onset of clinical symptoms and correlate with the severity of the disease

0 PlGF could be a promising biochemical marker even in the first trimester particularly if combined with HbF and A1M

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

0 PP13 has shown potential as a biochemical marker of early onset PE especially if combined with Doppler ultrasound uterine artery PI

0However as a general screening marker for all types of PE the data is conflicting and needs further investigation

0Restoration of angiogenesis balance in maternal circulation such as VEGF A 21 or neutralizing antibodies against sFlt-1 or sEnd may be the future therapy

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU

Preeclampsia may never be totally predictable

But better prediction would help to focus on

antenatal care more effectively

THANK YOU