Just a presentation covering most of the newer predictors of preeclampsia.

1. DR ANUSHA RAO P
PG II YR (OBG)

5. Traditional tests Novel predictors
• Roll-over test
• Isometric handgrip
or cold pressor test
• Angiotensin-II
infusion
• Midtrimester mean
arterial pressure
• Platelet angiotensin-
II binding
• Renin
• 24-hour ambulatory
blood pressure
monitoring
• Uterine artery or
fetal transcranial
Doppler velocimetry
• Human chorionic gonadotropin (hCG)
• Alpha-fetoprotein (AFP)
• Estriol
• Pregnancy- associated protein A (PAPP A)
• Inhibin A
• Activin A
• Placental protein 13
• Corticotropin- releasing hormone
• Microtransferrinuria
• N-acetyl-􏰂-glucosaminidase
• Platelet count and activation
• Endothelial adhesion molecules

6. TRADITIONAL TESTS NOVEL PREDICTORS
• Serum uric acid
• Microalbuminuria
• Urinary calcium or kallikrein
• Fibronectin
• Prostaglandin
• Thromboxane
• C-reactive protein
• Cytokines
• Endothelin
• Neurokinin B
• Homocysteine
• Lipids
• Antiphospholipid antibodies
• Plasminogen activator-inhibitor (PAI)

7. NOVEL PREDICTORS
• Leptin
• P-selectin
• Angiogenic factors to include placental growth
factor (PIGF), vascular endothelial growth factor
(VEGF), fms-like tyrosine kinase receptor-1 (sFLT-
1), Endoglin
• Antithrombin-III(AT-3)
• Atrial natriuretic peptide (ANP)
• 􏰂2-microglobulin
• Genetic markers
• Free fetal DNA
• Serum proteonomic markers

9. 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.
0 However, placental disorders can cause IUGR without PE and
vice versa, which makes the clinical evaluation of new markers
particularly hard.

10. 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 and/or, 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.

11. Angiotensin II sensitivity
0 Preeclamptic women show an elevated pressor response
to vasopressin.
0 Although the performance of the test had a 77%sensitivity
and 95% specificity in 1973,
0 The 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.
0 The disappointing results of recent studies raises doubts
about usefulness as a continuing test.

13. 0Urine albumin excretion rate was the best
predictive value for preeclampsia in hypertensive
patient when blood for fibronectin, anthithrombin
3,alpha 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 87.5 and 98.9
respectively

14. 0 Elevated 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.
0 However 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

15. 0 Rodriques and Susuki showed that in women with a low levels of
calcium/creatinine ratio and high microalbuminuria, 84%
developed PE.
0 Microproteinuria levels above 375mg/l may be significant and thus
could be utilized as a screening test for the early detection of a
woman at risk of developing preeclampsia.
0 However there is no diagnostic value of microalbuminuria and the
calcium/creatinine ratio when used alone.

16. 0 When 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 .
0 However urinary endoglin has limitations to determine the
severity of preeclampsia, and to differentiate between
preeclampsia and chronic hypertension

17. 0 Women with preeclampsia appear to present a unique urine
proteomicfingerprint 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 proteinuric
disorders in pregnancy.

18. 0 Urine levels of inhibin Ashowed the greatest discrimination
between severe preeclampsia and pregnant control women,
when there was cut off of 45pg/mg. for urine creatinine.
0 Women with greater than 90pg/mg urinary creatinine had a 17
fold relative risk of a clinically indicated delivery due to
preeclampsia.

19. 0 Measurement of urinary kallikrein(IUK)to
creatinine ratio(IUK:cr) 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

20. 0Urinary microtransferrinuria levels in
pregnant women who subsequently developed preeclampsia
and eclampsia where significantly higher than those pregnant
women who remained normotensive.
0 Microtranferrinuria as a predictor for preeclampsia had a
sensitivity 93.5%,specificity 65%,positive predictive value of
83% and a negative predictive value of 98.4%
0 Microtranferrinuria is potentially a more sensitive predictor of
preeclampsia than microalbuminuria.

21. 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.

23. 0Serum Inhibin–A was determined as a more sensitive
marker for the prediction of preeclampsia than hCG.
0 Addition 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.

24. 0 Midtrimester beta-hCG levels alone correlated significantly
with the severity of preeclampsia.
0 However the combination of MShCG levels, body mass
index(BMI),parity and age as a predictive test for preeclampsia
was far superior to MShCG alone.
0 This multi-factorial model could identify preeclampsia with a
sensitivity of 70% and a specificity of 71 %.

25. 0 Although the plasma TNF-alpha levels were higher
in preeclamptics compared with normotensives,the levels cannot
be used in the first, second trimester as a specific marker
0 However they may be useful in the early third trimester.

26. 0 Serum thrombomodulin antigenlevels 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.
0 Thrombomodulin may serve as a clinical marker to differentiate
preeclampsia from other disorders of pregnancy.

27. 0 low levels of SHBGin the first half of pregnancy were reported
as a promising early risk marker of the later development of
preeclampsia.
0 However as compared to normotensives controls, preeclamptic
women exhibited no statically significant differences in the
median levels of total testerone, free androgen index, sex
hormone binding globulin or dehydroepiandrosterone.

28. 0 Serum levels of collagen synthesis, procollagen I, carboxy-
terminal peptide (PICP) and procollagen111 amino-terminal
peptide (PIIIP), in patients with preeclampsia and controls.
0 The markers were mildly elevated in preeclampsia, but unlikely
to be useful in the prediction of preeclampsia.

29. 0 Mid-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)-6,8,10,11,12,15, 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 preeclampsia
are being studied.

30. 0Proteomics alterations in pre-eclampsia suggest that
possible cellular battle against mitochondria-originated oxidative
stress test resulting in recovery or apoptosis.
0 The over expression of chaperonin 60, GST, VDAC, Erp29 and
cathespin D in pre-eclampsia makes it a ideal marker of predicting
preeclampsia

31. 0 Serum CA125 variability.
0 Lipoprotein a-Lp(a)
0 Coagulation Factors and Platelets
0 Serum Oestriol
0 Maternal serum alpha fetoprotein (MSAFP)

32. 0Pregnancy – 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.

33. 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 .

34. 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 .

35. 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.

36. 0 When 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

37. 0 Elevated 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.
0 Early-onset PE exhibits higher levels of sFlt-1.
0 sFlt-1 increase is observed approximately 5 weeks
before onset of PE.

38. 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.

39. 0 As 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
77.8% at a false positive rate of 5% .

40. sFlt-1 levels are stable during early & mid gestation
,then increase significantly during late stages.
Angiogenic Markers In Healthy
Pregnancy

41. 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 &
high concentration of sFlt-1 a strong predictor of early PE.
0 Low increase in PlGF & 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 –PE.

42. Mean sFlt-1 concentration and gestational age

43. Mean PIGF concentration and gestational age

44. Latest results :sFLT-1 free VEGF not useful
in the 1st trimester screening
Measurement of free-VEGF and
sFlt-1 in maternal blood at 11 to 13 weeks of
gestation is not useful in the prediction of
pregnancies destined to develop PE.

45. 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 & PlGF obviously seen in PE.
0 Women with PE have reduced uteroplacental blood flow .
0 Several studies have shown the predictive power of PlGF/sFlt-1 ratio
from the second trimester.
0 The prediction rate is about 89% .
0 The transcription factor hypoxia –inducible factor 1 (HIF 1 alpha)
regulates VEGF & Flt-1gene transcription.
0 HIF-1 ,2 are elevated in pre eclamptic placenta.

46. Angiogenic Factors Prediction of PE
In High Risk Women
0 High risk women –Previous H/O PE, Multiple gestation, pre
gestational DM, Chronic hypertension, chronic kidney disease,
obesity & adolescent age.
0 Study revealed that Rapid rise in the sFlt-1 to PlGF ratio with
advancing gestation may be predictive of PE.
0 Mean serum sFlt-1, sFlt-1/PlGF were higher with early onset PE
(< 34 weeks)
0 Above ratio at 22-26 weeks was highly predictive of early onset
PE.
0 A 2 tiered screening approach may be a useful tool for
prediction.

47. 0 Twin 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 .
0 But not accompanied by any change in levels of sFlt-1 mRNA &
HIF – alpha protein, in the twin placentas, but were correlated
with placental weight.
0 Trisomy 13 a risk factor as gene for sFlt-1 is located on that
chromosome.
0 Smokers have low sFlt-1levels & less Incidence of PE.

48. 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.

49. 0Insulin-like growth factor-1 (IGF-1) is a hormone that
may be involved in both normal and abnormal fetal growth.
0 This hormone stimulates the renal and placental 1,25-
dihydroxyvitamin D synthesis.
0 It has been found that during preeclampsia the maternal IGF
concentrations are lower compared with those in normal
pregnancy.

50. 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.
0 This 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 cytotrophoblasts
obtained from the placental beds of preeclamptic pregnancies.

51. 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.
0 NGAL 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.
0 A 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

52. 0 Auto-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
0 Undoubtedly, 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 .

53. Angiotensin receptor activating autoantibodies (AT1-AAs) may underlie many
features of preeclampsia.AT1-AAs from preeclamptic patients activate angiotensin
receptors (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.

54. 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.

55. '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 & 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 it's 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.

56. Use of Doppler
Pre-eclampsia screening in the first trimester of
pregnancy:
0 The 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.

57. 0 Doppler studies of brachial artery reactivity in women
who have had pre-eclampsia show abnormal
endothelial dependent flow-mediated arterial dilation
three years after pregnancy.
0 A 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.

58. 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-eclampsia
and intrauterine growth restriction.
0 Women 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.

59. 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.
0 Abnormal Doppler is better in predicting severe
rather than mild pre-eclampsia. The sensitivity for
severe pre-eclampsia is about 75%.

60. conclusion
0 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 Down's
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, i.e. blood pressure, in term PE pregnancies .

61. 0 Angiogenic and anti-angiogenic factors are also very promising
biochemical markers.
0 Although the combination sFlt-1/PlGF 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.

62. 0 PP13 has shown potential as a biochemical marker of early
onset PE, especially if combined with Doppler ultrasound
uterine artery PI.
0 However, as a general screening marker for all types of PE, the
data is conflicting and needs further investigation.
0 Restoration of angiogenesis balance in maternal circulation
such as VEGF A 21 or neutralizing antibodies against sFlt-1 or
sEnd may be the future therapy.

63. Preeclampsia may never be totally predictable,
But better prediction would help to focus on
antenatal care more effectively
THANK YOU