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doi:10.1111/jog.12371
J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1540–1546, June 2014
Mid-trimester maternal serum and amniotic fluid biomarkers for the prediction of preterm delivery and intrauterine growth retardation A. Seval Ozgu-Erdinc, Sabri Cavkaytar, Ayla Aktulay, Umran Buyukkagnici, Salim Erkaya and Nuri Danisman Zekai Tahir Burak Women Health Care, Education and Research Hospital, Ankara, Turkey
Abstract Aim: Our purpose was to evaluate the predictive value of maternal serum and amniotic fluid biomarkers that were obtained at the time of genetic amniocentesis for preterm delivery and intrauterine growth retardation (IUGR). Methods: A prospective cohort analysis was conducted in 107 singleton pregnancies that underwent amniocentesis at 16–22 weeks according to standard genetic indications. Maternal blood and amniotic fluid obtained from genetic amniocentesis were tested for glucose, alkaline phosphatase (ALP), lactate dehydrogenase (LDH), ceruloplasmin, ferritin, high-sensitivity C-reactive protein and interleukin-6 (IL-6). Ninety-four pregnancies were followed until delivery. Results: Of the 94 patients, 16 (18.1%) delivered before 37 weeks and seven (7.5%) delivered a baby below the 10th percentile for gestational age. Amniotic fluid glucose levels were significantly lower in patients with preterm delivery than term deliveries (P = 0.01). Median amniotic fluid ferritin and IL-6 levels and mean amniotic fluid ALP levels were higher in the preterm group but this difference did not reach statistical significance. Mean maternal ALP and LDH levels tended to be insignificantly higher. Only median maternal blood ferritin levels in the IUGR group were found to be higher than patients who were appropriate for gestational age (P = 0.03). Conclusion: Low amniotic fluid glucose levels are associated with risk of preterm delivery, whereas high maternal blood ferritin levels increase the risk for IUGR. Although this result is significant and notable, there is not enough clinical evidence to recommend their use as a screening test for preterm delivery and IUGR in routine practice. Key words: amniotic fluid, biomarker, intrauterine growth retardation, mid-trimester, preterm delivery.
Introduction Preterm delivery (PD) and intrauterine growth retardation (IUGR) are the leading causes of perinatal
mortality and morbidity.1 Because the pathophysiology of PD and IUGR is not clear, there is no effective screening marker. For normal pregnancy maintenance and fetal development, placental structure and
Received: July 19 2013. Accepted: December 5 2013. Reprint request to: Dr A. Seval Ozgu-Erdinc, Zekai Tahir Burak Women Health Care, Education and Research Hospital, Talatpasa Bulvari, 06230, Ankara, Turkey. Email: [email protected] Note: This paper was selected as a poster presentation in the 12th World Congress in Fetal Medicine and Eurofetus meeting, Marbella, Spain, 23–27 June 2013. Funding sources: None.
1540
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Prediction of preterm delivery and IUGR
function is very important. Improper trophoblastic invasion and placentation may cause hypoxia in placenta leading to the release of reactive oxygen species, cytokines which result in inflammation.2 Low-grade inflammation has been described as a slightly elevated number of immune cells, pro-inflammatory proteins and acute phase proteins in healthy people, and associated with many diseases.3 In recent years, low-grade inflammation has been suggested as a possible mechanism for developing PD and IUGR.4,5 High-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL-6) are well-known markers of systemic inflammation and have been studied in several pregnancy complications.6–12 Alkaline phosphatase (ALP) rises during pregnancy due to the presence of placental isoenzyme. There are few reports on the role of ALP in the prediction of preterm delivery.13–15 Lactate dehydrogenase (LDH) is an intracellular cytoplasmic enzyme which catalyzes the final step in the glycolytic pathway and is found in most cells in the human body.16 The presence of LDH, an intracellular enzyme, in the extracellular space would suggest cell lysis and has been used as acute inflammation marker. Recently, high mid-trimester amniotic fluid LDH levels have been reported in preterm delivery.17,18 Ferritin is an acute-phase reactant and its concentration increases with inflammation.19 Several studies have reported altered serum ferritin concentrations in various pregnancy complications such as preterm delivery and fetal growth restriction.20,21 Ceruloplasmin is a member of the inflammation-sensitive protein family and related to systemic inflammation22 and some pathological conditions in pregnancy such as premature rupture of the membranes and pre-eclampsia.23,24 Amniotic fluid glucose levels were reported to be lower in women with preterm delivery when compared with women who delivered at term.25,26 In the light of these studies, we aimed to evaluate the role of mid-trimester maternal serum and amniotic fluid biomarkers of inflammation: hs-CRP, IL-6, ALP, LDH, ferritin, ceruloplasmin and glucose which are readily available, inexpensive and rapidly performed in any laboratory, in predicting preterm delivery and IUGR.
Methods Study design A prospective cohort analysis was conducted in 107 singleton pregnancies that underwent ultrasound guided transabdominal genetic amniocentesis at 16–22
weeks due to advanced maternal age (>35 years old) or increased risk for aneuploidy (abnormal triple test at second trimester, history of aneuploidy), at Ankara Zekai Tahir Burak Women Health Care, Education and Research Hospital, Perinatology Department. The study was approved by the institutional review board and informed consent was obtained from all participants before the procedure. Exclusion criteria included multiple pregnancy, patients with high risk for preterm delivery and IUGR (placenta previa, chronic or gestational hypertension, diabetes mellitus, thrombophilia, and history of lowbirthweight infant or preterm delivery), pregnancies with evidence of fetal structural or chromosomal abnormalities, maternal age of less than 18 years, women with abnormal uterine artery Doppler findings and vaginal discharge, and refusal to participate in the study. Preterm delivery was defined as the delivery of a fetus before 37 weeks of gestation.27 IUGR was defined by birthweight of less than the 10th percentile for gestational age.28 Gestational age was calculated from the last menstruation and confirmed at ultrasound examination in the first trimester.
Specimen collection Amniocentesis was performed with a 21-G needle under ultrasonographic guidance with freehand technique. The first 2 mL of amniotic fluid that was not used for genetic evaluation to avoid maternal contamination was collected with a 5-mL syringe and after being centrifuged at 1500 g for 10 min, amniotic fluid supernatant was processed for glucose, ALP, LDH, ceruloplasmin, ferritin, hs-CRP and IL-6. Glucose levels were measured by enzymatic colorimetric assay (Roche Diagnostics, Manheim, Germany). ALP levels were measured by colorimetric assay (Roche Diagnostics). LDH levels were measured by ultraviolet assay (Roche Diagnostics). Ferritin and IL-6 levels were measured by enzyme-linked immunosorbent assay (Diagnostic Products Biermann, BadNauheim, Germany). hs-CRP and ceruloplasmin levels were measured by immunoturbidimetric assay (Roche Diagnostics). Serum biochemical markers were measured at the same time with amniocentesis without considering the fasting status of women. Immediately after amniocentesis, 7 mL of venous blood sample was collected from all patients for the evaluation of serum glucose, ALP, LDH, ceruloplasmin, ferritin, hs-CRP and IL-6 concentrations. Within 1–2 h after amniocentesis, amniotic fluid and maternal serum
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
1541
A. S. Ozgu-Erdinc et al.
Table 1 Demographic features of patients
Age (years) Parity Non-smoking Body mass index Gestational age at sampling (weeks) Indication of amniocentesis Abnormal triple test Maternal age >35 years History of aneuploidy Gestational age at delivery (weeks) Birthweight Mean arterial pressure
Term delivery (n = 73)
Preterm delivery (n = 16)
IUGR (n = 7)
35 (19–44) 1 (0–5) 63 (86.3%) 26.3 ± 4.7 18.3 ± 1.5
35 (23–40) 1 (0–3) 10 (66.7%) 24.6 ± 4.2 18.8 ± 1.5
26.5 (21–37) 1 (0–3) 6 (100%) 27.7 ± 6.5 18.2 ± 2.2
33 (45.2%) 33 (45.2%) 7 (0.6%) 39 (37–42) 3394 ± 413 93.3 (73.3–101.7)
6 (37.5%) 6 (37.5%) 4 (25%) 35 (27–36.5) 2318 ± 600 93.3 (73.3–101.7)
5 (71.4%) 1 (14.3%) 1 (14.3%) 38.5 (36–42) 2418 ± 461 90 (80–101.7)
P 0.203 0.173 0.563 0.313 0.548 0.481
0.454
doi:10.1111/jog.12371
J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1540–1546, June 2014
Mid-trimester maternal serum and amniotic fluid biomarkers for the prediction of preterm delivery and intrauterine growth retardation A. Seval Ozgu-Erdinc, Sabri Cavkaytar, Ayla Aktulay, Umran Buyukkagnici, Salim Erkaya and Nuri Danisman Zekai Tahir Burak Women Health Care, Education and Research Hospital, Ankara, Turkey
Abstract Aim: Our purpose was to evaluate the predictive value of maternal serum and amniotic fluid biomarkers that were obtained at the time of genetic amniocentesis for preterm delivery and intrauterine growth retardation (IUGR). Methods: A prospective cohort analysis was conducted in 107 singleton pregnancies that underwent amniocentesis at 16–22 weeks according to standard genetic indications. Maternal blood and amniotic fluid obtained from genetic amniocentesis were tested for glucose, alkaline phosphatase (ALP), lactate dehydrogenase (LDH), ceruloplasmin, ferritin, high-sensitivity C-reactive protein and interleukin-6 (IL-6). Ninety-four pregnancies were followed until delivery. Results: Of the 94 patients, 16 (18.1%) delivered before 37 weeks and seven (7.5%) delivered a baby below the 10th percentile for gestational age. Amniotic fluid glucose levels were significantly lower in patients with preterm delivery than term deliveries (P = 0.01). Median amniotic fluid ferritin and IL-6 levels and mean amniotic fluid ALP levels were higher in the preterm group but this difference did not reach statistical significance. Mean maternal ALP and LDH levels tended to be insignificantly higher. Only median maternal blood ferritin levels in the IUGR group were found to be higher than patients who were appropriate for gestational age (P = 0.03). Conclusion: Low amniotic fluid glucose levels are associated with risk of preterm delivery, whereas high maternal blood ferritin levels increase the risk for IUGR. Although this result is significant and notable, there is not enough clinical evidence to recommend their use as a screening test for preterm delivery and IUGR in routine practice. Key words: amniotic fluid, biomarker, intrauterine growth retardation, mid-trimester, preterm delivery.
Introduction Preterm delivery (PD) and intrauterine growth retardation (IUGR) are the leading causes of perinatal
mortality and morbidity.1 Because the pathophysiology of PD and IUGR is not clear, there is no effective screening marker. For normal pregnancy maintenance and fetal development, placental structure and
Received: July 19 2013. Accepted: December 5 2013. Reprint request to: Dr A. Seval Ozgu-Erdinc, Zekai Tahir Burak Women Health Care, Education and Research Hospital, Talatpasa Bulvari, 06230, Ankara, Turkey. Email: [email protected] Note: This paper was selected as a poster presentation in the 12th World Congress in Fetal Medicine and Eurofetus meeting, Marbella, Spain, 23–27 June 2013. Funding sources: None.
1540
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Prediction of preterm delivery and IUGR
function is very important. Improper trophoblastic invasion and placentation may cause hypoxia in placenta leading to the release of reactive oxygen species, cytokines which result in inflammation.2 Low-grade inflammation has been described as a slightly elevated number of immune cells, pro-inflammatory proteins and acute phase proteins in healthy people, and associated with many diseases.3 In recent years, low-grade inflammation has been suggested as a possible mechanism for developing PD and IUGR.4,5 High-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL-6) are well-known markers of systemic inflammation and have been studied in several pregnancy complications.6–12 Alkaline phosphatase (ALP) rises during pregnancy due to the presence of placental isoenzyme. There are few reports on the role of ALP in the prediction of preterm delivery.13–15 Lactate dehydrogenase (LDH) is an intracellular cytoplasmic enzyme which catalyzes the final step in the glycolytic pathway and is found in most cells in the human body.16 The presence of LDH, an intracellular enzyme, in the extracellular space would suggest cell lysis and has been used as acute inflammation marker. Recently, high mid-trimester amniotic fluid LDH levels have been reported in preterm delivery.17,18 Ferritin is an acute-phase reactant and its concentration increases with inflammation.19 Several studies have reported altered serum ferritin concentrations in various pregnancy complications such as preterm delivery and fetal growth restriction.20,21 Ceruloplasmin is a member of the inflammation-sensitive protein family and related to systemic inflammation22 and some pathological conditions in pregnancy such as premature rupture of the membranes and pre-eclampsia.23,24 Amniotic fluid glucose levels were reported to be lower in women with preterm delivery when compared with women who delivered at term.25,26 In the light of these studies, we aimed to evaluate the role of mid-trimester maternal serum and amniotic fluid biomarkers of inflammation: hs-CRP, IL-6, ALP, LDH, ferritin, ceruloplasmin and glucose which are readily available, inexpensive and rapidly performed in any laboratory, in predicting preterm delivery and IUGR.
Methods Study design A prospective cohort analysis was conducted in 107 singleton pregnancies that underwent ultrasound guided transabdominal genetic amniocentesis at 16–22
weeks due to advanced maternal age (>35 years old) or increased risk for aneuploidy (abnormal triple test at second trimester, history of aneuploidy), at Ankara Zekai Tahir Burak Women Health Care, Education and Research Hospital, Perinatology Department. The study was approved by the institutional review board and informed consent was obtained from all participants before the procedure. Exclusion criteria included multiple pregnancy, patients with high risk for preterm delivery and IUGR (placenta previa, chronic or gestational hypertension, diabetes mellitus, thrombophilia, and history of lowbirthweight infant or preterm delivery), pregnancies with evidence of fetal structural or chromosomal abnormalities, maternal age of less than 18 years, women with abnormal uterine artery Doppler findings and vaginal discharge, and refusal to participate in the study. Preterm delivery was defined as the delivery of a fetus before 37 weeks of gestation.27 IUGR was defined by birthweight of less than the 10th percentile for gestational age.28 Gestational age was calculated from the last menstruation and confirmed at ultrasound examination in the first trimester.
Specimen collection Amniocentesis was performed with a 21-G needle under ultrasonographic guidance with freehand technique. The first 2 mL of amniotic fluid that was not used for genetic evaluation to avoid maternal contamination was collected with a 5-mL syringe and after being centrifuged at 1500 g for 10 min, amniotic fluid supernatant was processed for glucose, ALP, LDH, ceruloplasmin, ferritin, hs-CRP and IL-6. Glucose levels were measured by enzymatic colorimetric assay (Roche Diagnostics, Manheim, Germany). ALP levels were measured by colorimetric assay (Roche Diagnostics). LDH levels were measured by ultraviolet assay (Roche Diagnostics). Ferritin and IL-6 levels were measured by enzyme-linked immunosorbent assay (Diagnostic Products Biermann, BadNauheim, Germany). hs-CRP and ceruloplasmin levels were measured by immunoturbidimetric assay (Roche Diagnostics). Serum biochemical markers were measured at the same time with amniocentesis without considering the fasting status of women. Immediately after amniocentesis, 7 mL of venous blood sample was collected from all patients for the evaluation of serum glucose, ALP, LDH, ceruloplasmin, ferritin, hs-CRP and IL-6 concentrations. Within 1–2 h after amniocentesis, amniotic fluid and maternal serum
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
1541
A. S. Ozgu-Erdinc et al.
Table 1 Demographic features of patients
Age (years) Parity Non-smoking Body mass index Gestational age at sampling (weeks) Indication of amniocentesis Abnormal triple test Maternal age >35 years History of aneuploidy Gestational age at delivery (weeks) Birthweight Mean arterial pressure
Term delivery (n = 73)
Preterm delivery (n = 16)
IUGR (n = 7)
35 (19–44) 1 (0–5) 63 (86.3%) 26.3 ± 4.7 18.3 ± 1.5
35 (23–40) 1 (0–3) 10 (66.7%) 24.6 ± 4.2 18.8 ± 1.5
26.5 (21–37) 1 (0–3) 6 (100%) 27.7 ± 6.5 18.2 ± 2.2
33 (45.2%) 33 (45.2%) 7 (0.6%) 39 (37–42) 3394 ± 413 93.3 (73.3–101.7)
6 (37.5%) 6 (37.5%) 4 (25%) 35 (27–36.5) 2318 ± 600 93.3 (73.3–101.7)
5 (71.4%) 1 (14.3%) 1 (14.3%) 38.5 (36–42) 2418 ± 461 90 (80–101.7)
P 0.203 0.173 0.563 0.313 0.548 0.481
0.454
