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Thrombophilia is a risk factor for severe preeclampsia and its recurrence
S6 SMFM Abstracts 9
10
TOLL-LIKE RECEPTOR 4: A LINK BETWEEN ‘‘DANGER SIGNALS’’, THE INNATE IMMUNE SYSTEM, TROPHOBLAST APOPTOSIS AND PREECLAMPSIA? YEON MEE KIM1, SEO YOUNG OH2, JYH KAE NIEN2, RICARDO GOMEZ3, CHONG JAI KIM4, MOSHE MAZOR5, VIKKI ABRAHAMS6, GIL MOR6, SHIGERU SAITO7, ROBERTO ROMERO2, 1 Wayne State University School of Medicine, Department of Pathology, Detroit, Michigan, 2Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, 3CEDIP, Sotero del Rio Hospital, Puente Alto, Chile, Chile, 4Seoul National University, Seoul, Korea, South Korea, 5Soroka University Medical Center, Beer Sheva, Israel, Israel, 6Yale University, Department of Obstetrics and Gynecology, New Haven, Connecticut, 7Toyama Medical and Pharmaceutical University, Department of Obstetrics and Gynecology, Toyama, Japan, Japan OBJECTIVE: Toll-like receptors (TLRs), discovered to regulate patterning during embryonic development, were subsequently found to play a role in innate immunity. TLRs recognize microbial ligands as well as host products released during tissue damage or ‘‘danger signals’’ (Science 2002;296:301). Engagement of TLR-4 can induce trophoblast cells to produce pro-inflammatory cytokines. Such cytokines may promote trophoblast cell apoptosis, which is increased in preeclampsia. This study was conducted to determine TLR-4 expression patterns in the extravillous trophoblasts (EVT) in the placental bed of women with and without preeclampsia. STUDY DESIGN: Placental bed biopsies were obtained from patients with: (1) normal pregnancy at term (n = 40); (2) severe preeclampsia (n = 15); and (3) preterm delivery and intact membranes (PTD) with and without histologic chorioamnionitis (n = 15 for each group). The expression pattern of TLR-4 in the EVT was examined by double immunohistochemistry. Image analysis was conducted and non-parametric statistics were employed for analysis. RESULTS: (1) The median percentage of TLR-4 positive EVT was significantly higher in patients with preeclampsia than in patients with PTD or normal patients at term (PTD: P = .0001; women at term: P ! .0001). (2) The median percentage of TLR-4 positive EVT was significantly higher in patients with preeclampsia than in those with PTD with histologic chorioamnionitis (P = .0057). (3) The median percentage of TLR-4 positive EVT in the placental bed was significantly higher in patients with PTL and histologic chorioamnionitis than in those without these conditions (P = .037). CONCLUSION: TLR-4 expression is increased in the extravillous trophoblasts in women with preeclampsia. We propose that ‘‘danger signals’’ may increase the expression of TLR-4 by EVT in the placental bed, which might lead to trophoblast apoptosis and defective hemochorional placentation in preeclampsia. URINARY PLACENTAL GROWTH FACTOR (PGF) AND THE RISK OF PREECLAMPSIA RICHARD LEVINE1, RAVI THADHANI2, CONG QIAN3, CHUN LAM4, KEE-HAK LIM4, KAI YU1, ANASTASIA BLINK1, BENJAMIN SACHS4, FRANKLIN EPSTEIN4, BAHA SIBAI5, VIKAS SUKHATME4, ANANTH KARUMANCHI4, 1Department of Health and Human Services, National Institute of Child Health and Human Development, Epidemiology and Biometry, Bethesda, Maryland, 2Massachusetts General Hospital, Medicine and Obstetrics, Boston, Massachusetts, 3Allied Technology Group, Rockville, Maryland, 4Beth Israel Deaconess Medical Center, Medicine and Obstetrics, Boston, Massachusetts, 5University of Cincinnati College of Medicine, Obstetrics and Gynecology, Cincinnati, Ohio OBJECTIVE: Preeclampsia may be caused by an imbalance of angiogenic factors. We previously demonstrated that high serum levels of sFlt1 (an antiangiogenic protein) and low levels of PGF (a pro-angiogenic protein) predict subsequent development of preeclampsia. While sFlt1 is too large a molecule (110 kD) to be filtered into the urine, PGF is much smaller (30 kD) and readily filtered. We hypothesized that urine PGF is altered prior to hypertension and proteinuria and may predict preeclampsia. STUDY DESIGN: Nested case control study within the CPEP cohort of healthy nulliparas. Each woman who developed preeclampsia was matched to one normotensive control. 120 pairs were randomly chosen. Concentrations of PGF and creatinine were determined in 704 urine specimens obtained before labor. RESULTS: Among normotensive controls urinary PGF increased during the first 2 trimesters, peaked at 29-32 weeks, and decreased thereafter. The pattern in cases before onset of preeclampsia was similar, but levels were significantly reduced beginning at 25-28 weeks. There were particularly large differences between controls and cases with subsequent early-onset preeclampsia or an SGA infant. The adjusted odds ratio for subsequent preeclampsia before 37 wks for specimens obtained at 21-32 weeks which were in the lowest quartile of control
PGF concentrations (!118 pg/mL), as compared to all other quartiles, was 22.5 (95% CI 7.4-67.8). CONCLUSION: Decreased urinary PGF increases greatly the risk of preeclampsia.
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THROMBOPHILIA IS A RISK FACTOR FOR SEVERE PREECLAMPSIA AND ITS RECURRENCE FABIO FACCHINETTI1, ELENA PARRETTI2, LUCA MAROZIO3, ANDREA LOIACONO4, PAOLO VENTURINI1, CHIARA BENEDETTO3, TIZIANA FRUSCA4, GIORGIO MELLO2, 1Univ. of Modena & Reggio Emilia, Mother-Infant Dept, Modena, Italy, 2Univ. of Florence, High-Risk Pregnancy Unit, Florence, Italy, 3 Univ. of Torino, Dept. Obstet Gynecol, Torino, Italy, 4Univ. of Brescia, Dept. Obstet. Gynecol., Brescia, Italy OBJECTIVE: To assess if thrombophilia increases the risk for Preeclampsia (PE) development and interferes with the clinical course, in a homogeneous population enrolled with standardized criteria. STUDY DESIGN: In a multicentre, case-control study 808 caucasian patients having developed PE according to ACOG definition were evaluated for the presence of the thrombophilic factors reported in the Table. The same evaluations were done in 808 women having had an uneventful pregnancy, matched for age and parity. Blood sampling occurred 4-12 months from last pregnancy. RESULTS: Except PS-PC-AT deficit, each one of the thrombophilic factors was associated (P ! .0001) with an increased risk for severe PE onset while mild to moderate form were not associated with thrombophilia. In severe PE, the presence of any of the thrombophilic factor increased the risk of recurrency (OR: 7.0, 95% CI:3.2-15.5, P = .0001) as well as of other obstetric complications. Moreover, thrombophilic patients are at increased risk for acute renal failure (OR: 1.8, 95% CI:1.5-2.2, P = .0006), Disseminated Intravascular Coagulation (OR: 2.7, 95% CI:1.1-6.4, P = .021), Thrombocytopenia (OR: 3.1, 95% CI:1.56.0, P = .0005) and perinatal mortality (OR: 1.7, 95% CI:1.5-2.2, P = .0006) respect with non thrombophilic ones. CONCLUSION: In the counselling to caucasian women, the screening for thrombophilia should be guaranteed to patients with a history of severe PE. Factor
Severe PE
Controls
OR
F VLeiden +/+ or +/FII G20210A +/MTHFR C677T +/+ Hyper Hcy PS PC AT def. APL Ab Combined defects Any defect
68 44 49 49 3 52 59 206
15 8 13 21 2 15 4 70
5.2 6.0 4.1 2.5 1.2 3.8 17.1 4.9
(16.7%) (10.8%) (12.1%) (12.1%) (0.7%) (12.8%) (14.5%) (50.7%)
(3.7%) (2.0%) (3.2%) (5.2%) (0.5%) (3.7%) (1.0%) (17.2%)
(2.9-9.8) (2.7-14.1) (2.1-4.2) (1.4-4.4) (0.6-2.5) (2.1-7.2) (5.9-55.9) (3.5-6.9)
THE EFFECTS OF TREATMENT WITH N-ACETYLCYSTEINE (NAC) IN A RAT MODEL OF PREECLAMPSIA EUGENE CHANG1, ERNEST BARBOSA2, INDERJIT SINGH3, AVTAR SINGH4, MANJEET PAINTILIA3, 1Medical University of South Carolina, Obstetrics and Gynecology, Charleston, South Carolina, 2Medical University of South Carolina, Departments of Pediatrics and Neurology, Charleston, South Carolina, 3Medical University of South Carolina, Department of Pediatrics, Charleston, South Carolina, 4Medical University of South Carolina and Ralph Johnson VA Medical Center, Department of Pathology and Laboratory Medicine, Charleston, South Carolina OBJECTIVE: To determine whether NAC attenuates the maternal and fetal changes seen in a reduced uterine perfusion pressure (RUPP) model of preeclampsia. STUDY DESIGN: The RUPP model, an established model of preeclampsia in rats, was used to induce preeclampsia in pregnant Sprague-Dawley rats. Animals were selected to undergo sham surgery or the RUPP procedure. On day 15/22 of pregnancy, in animals undergoing the RUPP procedure, a laparotomy was performed and the infra-renal aorta and ovarian vessels were partially occluded using calibrated clips. The RUPP animals were assigned to treatment with NAC (100mg/kg BID) or no treatment. The first dose of NAC was given prior to the RUPP procedure. On day 21/22, carotid catheters were placed and mean arterial pressures were measured. The pups were delivered by hysterotomy and weighed. They were sacrificed and brain weights were determined. Placental tissue and pup brains were fixed in formalin or snap frozen. Statistical analysis was performed using one-way ANOVA and Dunnett’s method for post-hoc comparisons with a = .05. RESULTS: Results are shown in the table below. Rats undergoing the RUPP procedure demonstrated significantly higher mean arterial blood pressures, smaller pups, and smaller pup brain weights than the sham animals. Treatment with NAC, attenuated the blood pressure changes and improved both pup weights and pup brain weights. CONCLUSION: The use of NAC reduced blood pressure, improved pup weights, and pup brain weights in the RUPP model of preeclampsia. Maternal and fetal outcomes (*P ! .05)
Urinary PGF at 21-32 weeks by preeclampsia status and severity
Parameter
Sham
RUPP
RUPP + NAC
Number of animals Average BP Average litter size Average pup weight Average pup brain weight
5 72.24 mm Hg 11.2 4.37 g 0.175 g
5 85.78 mm Hg* 8.8 3.09 g* 0.149 g*
5 65.58 mm Hg* 10.4 4.58 g 0.183 g
10
TOLL-LIKE RECEPTOR 4: A LINK BETWEEN ‘‘DANGER SIGNALS’’, THE INNATE IMMUNE SYSTEM, TROPHOBLAST APOPTOSIS AND PREECLAMPSIA? YEON MEE KIM1, SEO YOUNG OH2, JYH KAE NIEN2, RICARDO GOMEZ3, CHONG JAI KIM4, MOSHE MAZOR5, VIKKI ABRAHAMS6, GIL MOR6, SHIGERU SAITO7, ROBERTO ROMERO2, 1 Wayne State University School of Medicine, Department of Pathology, Detroit, Michigan, 2Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, 3CEDIP, Sotero del Rio Hospital, Puente Alto, Chile, Chile, 4Seoul National University, Seoul, Korea, South Korea, 5Soroka University Medical Center, Beer Sheva, Israel, Israel, 6Yale University, Department of Obstetrics and Gynecology, New Haven, Connecticut, 7Toyama Medical and Pharmaceutical University, Department of Obstetrics and Gynecology, Toyama, Japan, Japan OBJECTIVE: Toll-like receptors (TLRs), discovered to regulate patterning during embryonic development, were subsequently found to play a role in innate immunity. TLRs recognize microbial ligands as well as host products released during tissue damage or ‘‘danger signals’’ (Science 2002;296:301). Engagement of TLR-4 can induce trophoblast cells to produce pro-inflammatory cytokines. Such cytokines may promote trophoblast cell apoptosis, which is increased in preeclampsia. This study was conducted to determine TLR-4 expression patterns in the extravillous trophoblasts (EVT) in the placental bed of women with and without preeclampsia. STUDY DESIGN: Placental bed biopsies were obtained from patients with: (1) normal pregnancy at term (n = 40); (2) severe preeclampsia (n = 15); and (3) preterm delivery and intact membranes (PTD) with and without histologic chorioamnionitis (n = 15 for each group). The expression pattern of TLR-4 in the EVT was examined by double immunohistochemistry. Image analysis was conducted and non-parametric statistics were employed for analysis. RESULTS: (1) The median percentage of TLR-4 positive EVT was significantly higher in patients with preeclampsia than in patients with PTD or normal patients at term (PTD: P = .0001; women at term: P ! .0001). (2) The median percentage of TLR-4 positive EVT was significantly higher in patients with preeclampsia than in those with PTD with histologic chorioamnionitis (P = .0057). (3) The median percentage of TLR-4 positive EVT in the placental bed was significantly higher in patients with PTL and histologic chorioamnionitis than in those without these conditions (P = .037). CONCLUSION: TLR-4 expression is increased in the extravillous trophoblasts in women with preeclampsia. We propose that ‘‘danger signals’’ may increase the expression of TLR-4 by EVT in the placental bed, which might lead to trophoblast apoptosis and defective hemochorional placentation in preeclampsia. URINARY PLACENTAL GROWTH FACTOR (PGF) AND THE RISK OF PREECLAMPSIA RICHARD LEVINE1, RAVI THADHANI2, CONG QIAN3, CHUN LAM4, KEE-HAK LIM4, KAI YU1, ANASTASIA BLINK1, BENJAMIN SACHS4, FRANKLIN EPSTEIN4, BAHA SIBAI5, VIKAS SUKHATME4, ANANTH KARUMANCHI4, 1Department of Health and Human Services, National Institute of Child Health and Human Development, Epidemiology and Biometry, Bethesda, Maryland, 2Massachusetts General Hospital, Medicine and Obstetrics, Boston, Massachusetts, 3Allied Technology Group, Rockville, Maryland, 4Beth Israel Deaconess Medical Center, Medicine and Obstetrics, Boston, Massachusetts, 5University of Cincinnati College of Medicine, Obstetrics and Gynecology, Cincinnati, Ohio OBJECTIVE: Preeclampsia may be caused by an imbalance of angiogenic factors. We previously demonstrated that high serum levels of sFlt1 (an antiangiogenic protein) and low levels of PGF (a pro-angiogenic protein) predict subsequent development of preeclampsia. While sFlt1 is too large a molecule (110 kD) to be filtered into the urine, PGF is much smaller (30 kD) and readily filtered. We hypothesized that urine PGF is altered prior to hypertension and proteinuria and may predict preeclampsia. STUDY DESIGN: Nested case control study within the CPEP cohort of healthy nulliparas. Each woman who developed preeclampsia was matched to one normotensive control. 120 pairs were randomly chosen. Concentrations of PGF and creatinine were determined in 704 urine specimens obtained before labor. RESULTS: Among normotensive controls urinary PGF increased during the first 2 trimesters, peaked at 29-32 weeks, and decreased thereafter. The pattern in cases before onset of preeclampsia was similar, but levels were significantly reduced beginning at 25-28 weeks. There were particularly large differences between controls and cases with subsequent early-onset preeclampsia or an SGA infant. The adjusted odds ratio for subsequent preeclampsia before 37 wks for specimens obtained at 21-32 weeks which were in the lowest quartile of control
PGF concentrations (!118 pg/mL), as compared to all other quartiles, was 22.5 (95% CI 7.4-67.8). CONCLUSION: Decreased urinary PGF increases greatly the risk of preeclampsia.
11
12
THROMBOPHILIA IS A RISK FACTOR FOR SEVERE PREECLAMPSIA AND ITS RECURRENCE FABIO FACCHINETTI1, ELENA PARRETTI2, LUCA MAROZIO3, ANDREA LOIACONO4, PAOLO VENTURINI1, CHIARA BENEDETTO3, TIZIANA FRUSCA4, GIORGIO MELLO2, 1Univ. of Modena & Reggio Emilia, Mother-Infant Dept, Modena, Italy, 2Univ. of Florence, High-Risk Pregnancy Unit, Florence, Italy, 3 Univ. of Torino, Dept. Obstet Gynecol, Torino, Italy, 4Univ. of Brescia, Dept. Obstet. Gynecol., Brescia, Italy OBJECTIVE: To assess if thrombophilia increases the risk for Preeclampsia (PE) development and interferes with the clinical course, in a homogeneous population enrolled with standardized criteria. STUDY DESIGN: In a multicentre, case-control study 808 caucasian patients having developed PE according to ACOG definition were evaluated for the presence of the thrombophilic factors reported in the Table. The same evaluations were done in 808 women having had an uneventful pregnancy, matched for age and parity. Blood sampling occurred 4-12 months from last pregnancy. RESULTS: Except PS-PC-AT deficit, each one of the thrombophilic factors was associated (P ! .0001) with an increased risk for severe PE onset while mild to moderate form were not associated with thrombophilia. In severe PE, the presence of any of the thrombophilic factor increased the risk of recurrency (OR: 7.0, 95% CI:3.2-15.5, P = .0001) as well as of other obstetric complications. Moreover, thrombophilic patients are at increased risk for acute renal failure (OR: 1.8, 95% CI:1.5-2.2, P = .0006), Disseminated Intravascular Coagulation (OR: 2.7, 95% CI:1.1-6.4, P = .021), Thrombocytopenia (OR: 3.1, 95% CI:1.56.0, P = .0005) and perinatal mortality (OR: 1.7, 95% CI:1.5-2.2, P = .0006) respect with non thrombophilic ones. CONCLUSION: In the counselling to caucasian women, the screening for thrombophilia should be guaranteed to patients with a history of severe PE. Factor
Severe PE
Controls
OR
F VLeiden +/+ or +/FII G20210A +/MTHFR C677T +/+ Hyper Hcy PS PC AT def. APL Ab Combined defects Any defect
68 44 49 49 3 52 59 206
15 8 13 21 2 15 4 70
5.2 6.0 4.1 2.5 1.2 3.8 17.1 4.9
(16.7%) (10.8%) (12.1%) (12.1%) (0.7%) (12.8%) (14.5%) (50.7%)
(3.7%) (2.0%) (3.2%) (5.2%) (0.5%) (3.7%) (1.0%) (17.2%)
(2.9-9.8) (2.7-14.1) (2.1-4.2) (1.4-4.4) (0.6-2.5) (2.1-7.2) (5.9-55.9) (3.5-6.9)
THE EFFECTS OF TREATMENT WITH N-ACETYLCYSTEINE (NAC) IN A RAT MODEL OF PREECLAMPSIA EUGENE CHANG1, ERNEST BARBOSA2, INDERJIT SINGH3, AVTAR SINGH4, MANJEET PAINTILIA3, 1Medical University of South Carolina, Obstetrics and Gynecology, Charleston, South Carolina, 2Medical University of South Carolina, Departments of Pediatrics and Neurology, Charleston, South Carolina, 3Medical University of South Carolina, Department of Pediatrics, Charleston, South Carolina, 4Medical University of South Carolina and Ralph Johnson VA Medical Center, Department of Pathology and Laboratory Medicine, Charleston, South Carolina OBJECTIVE: To determine whether NAC attenuates the maternal and fetal changes seen in a reduced uterine perfusion pressure (RUPP) model of preeclampsia. STUDY DESIGN: The RUPP model, an established model of preeclampsia in rats, was used to induce preeclampsia in pregnant Sprague-Dawley rats. Animals were selected to undergo sham surgery or the RUPP procedure. On day 15/22 of pregnancy, in animals undergoing the RUPP procedure, a laparotomy was performed and the infra-renal aorta and ovarian vessels were partially occluded using calibrated clips. The RUPP animals were assigned to treatment with NAC (100mg/kg BID) or no treatment. The first dose of NAC was given prior to the RUPP procedure. On day 21/22, carotid catheters were placed and mean arterial pressures were measured. The pups were delivered by hysterotomy and weighed. They were sacrificed and brain weights were determined. Placental tissue and pup brains were fixed in formalin or snap frozen. Statistical analysis was performed using one-way ANOVA and Dunnett’s method for post-hoc comparisons with a = .05. RESULTS: Results are shown in the table below. Rats undergoing the RUPP procedure demonstrated significantly higher mean arterial blood pressures, smaller pups, and smaller pup brain weights than the sham animals. Treatment with NAC, attenuated the blood pressure changes and improved both pup weights and pup brain weights. CONCLUSION: The use of NAC reduced blood pressure, improved pup weights, and pup brain weights in the RUPP model of preeclampsia. Maternal and fetal outcomes (*P ! .05)
Urinary PGF at 21-32 weeks by preeclampsia status and severity
Parameter
Sham
RUPP
RUPP + NAC
Number of animals Average BP Average litter size Average pup weight Average pup brain weight
5 72.24 mm Hg 11.2 4.37 g 0.175 g
5 85.78 mm Hg* 8.8 3.09 g* 0.149 g*
5 65.58 mm Hg* 10.4 4.58 g 0.183 g