Research

www. AJOG.org

OBSTETRICS

Can placental growth factor in maternal circulation identify

fetuses with placental intrauterine growth restriction?
Samantha J. Benton, BSc; Yuxiang Hu, MD; Fang Xie, MD, PhD; Kenneth Kupfer, PhD;
Seok-Won Lee, PhD; Laura A. Magee, MD, MSc; Peter von Dadelszen, MBChB, DPhil
OBJECTIVE: We investigated whether decreased concentrations of pla-

cental growth factor (PlGF) in maternal circulation differentiated placental intrauterine growth restriction (IUGR) from constitutionally small fetuses. Excluding congenital syndromes, infection, and aneuploidy, we
assumed IUGR with an abnormal placental pathology to be of placental
origin.
STUDY DESIGN: The study design included a single site, case-

control study of 16 cases (9 placental IUGR, 7 constitutionally

small) and 79 normal controls with singleton pregnancies. Plasma
PlGF was measured by Triage PlGF immunoassay according to the
product insert. A positive PlGF test was defined as a concentra-

tion less than the fifth percentile for gestational age for normal
pregnancy.
RESULTS: A positive PlGF test was found in 9 of 9 placental IUGR cases,

1 of 7 constitutionally small fetuses, and 4 of 79 controls (P .0001).

PlGF identified placental IUGR from constitutionally small fetuses with
100% sensitivity and 86% specificity (P .0009).
CONCLUSION: These preliminary data suggest PlGF may identify pla-

cental IUGR antenatally.

Key words: angiogenesis, constitutionally small fetus, diagnostic test,
placental growth factor, placental IUGR

Cite this article as: Benton SJ, Hu Y, Xie F, et al. Can placental growth factor in maternal circulation identify fetuses with placental intrauterine growth restriction?
Am J Obstet Gynecol 2012;206:163.e1-7.

etuses with abdominal circumferences (AC) below the 10th percentile for gestational age on antenatal ultrasound attract increased clinical attention
because of the potential for adverse pregnancy outcomes as a result of poor in
utero growth. However, fetuses with AC
10th percentile can be divided into 2
main populations: those who are constitutionally small (small but healthy fetuses)

and those who are pathologically growth

restricted.
Intrauterine growth restriction (IUGR)
is a leading cause of perinatal mortality
and morbidity.1-4 This group of pathologically growth-restricted fetuses can be
further subdivided into 2 main groups:
those with placental IUGR and those
with syndromic IUGR (arising from
congential infection, fetal syndromes,

From the Department of Obstetrics and Gynaecology and the Child and Family Research
Institute (Ms Benton and Drs Hu, Xie, Magee, and von Dadelszen) and the Department of
Medicine (Dr Magee), Faculty of Medicine, University of British Columbia, Vancouver, BC,
Canada, and Alere San Diego, Inc, San Diego, CA (Drs Kupfer and Lee).
Received Feb. 21, 2011; revised July 27, 2011; accepted Sept. 21, 2011.
This study was supported by a New Investigator Pilot Project Grant from the Institute of Infection
and Immunity, Canadian Institutes of Health Research (P.v.D.), and funded in part by Alere
International. Additional funding was derived from salary awards from the Michael Smith
Foundation for Health Research (L.A.M. and P.v.D.), Canadian Institutes of Health Research
(P.v.D.), and the Child and Family Research Institute (P.v.D. and S.B.).
P.v.D. is a principal investigator for an investigator-initiated safety and efficacy trial of a possible
disease-modifying therapy for preeclampsia sponsored by Eli Lilly, Canada, and is a site
investigator for a preeclampsia prediction study sponsored by Alere International. He is also a
consultant for Alere International. K.K. is an employee of Alere San Diego. S.-W.L. is a former
employee of Alere San Diego.
Presented at the International Federation of Placenta Associations Meeting 2011, Geil, Norway,
Sept. 14-17, 2011.
Reprints: Peter von Dadelszen, MBChB, DPhil, 2H30-4500 Oak St., Vancouver, BC V6H 3N1,
Canada. pvd@cw.bc.ca.
0002-9378/$36.00 2012 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.09.019

and/or aneuploidy). Placental IUGR is of

serious clinical concern because these
fetuses are at increased risk for intrauterine fetal demise, preterm delivery,
and subsequent developmental sequelae
as a consequence of exposure to placental dysfunction.5-10
Constitutionally small fetuses and fetuses with placental IUGR are difficult to
differentiate clinically. As such, constitutionally small (and healthy) fetuses may be
followed up as though they are high risk,
adding unnecessary burden to families and
the health care system. These fetuses will be
at risk for adverse events such as iatrogenic
preterm delivery should they be misdiagnosed as placental IUGR.
The ability to tailor assessment and
surveillance to accurately determine the
presence or absence of placental IUGR
would represent a significant advance in
antenatal care. Biomarkers present in
maternal circulation that are reflective of
placental functional status may provide
this vital piece of additional information.
Additional surveillance tools would help
to streamline and improve care for the
high-risk fetus (placental IUGR) and
avoid unnecessary monitoring, health
care costs, and parental anxiety for the
low-risk fetus (constitutionally small).

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Research

Obstetrics

Angiogenesis is the formation of new

blood vessels from existing endothelium
and is a key component of placental formation. It is mediated by various factors
that either promote or restrict vessel formation and is critical for development of
a healthy placenta and fetus. Placental
growth factor (PlGF) is a key factor in
these angiogenic processes and is present
in maternal circulation and placental tissues during pregnancy.11,12 In normal
pregnancy, PlGF levels gradually increase until the end of the second trimester and then decrease gradually until delivery. Decreased PlGF in maternal circulation
is characteristic of preeclampsia, another obstetrical complication related to placental
dysfunction.
Studies suggest that low PlGF in preeclampsia may have diagnostic utility,
especially in cases in which the etiology is related to placental implications.13-18 Some of these studies have
also reported decreased PlGF concentrations in the circulation of women
who deliver small-for-gestational-age
(SGA) infants. However, these studies
used varying birthweight cutoffs to define SGA and failed to categorize pregnancies based on the cause of SGA
(pathological or physiological). In addition, most research has investigated
PlGF alterations in pregnancies delivering SGA fetuses only in association
with preeclampsia, not in normotensive women. The relationship between
maternal levels of PlGF and fetuses
with and without placental IUGR remains to be further elucidated.
We propose that differences in maternal PlGF concentrations may have
the ability to discriminate between fetuses with placental IUGR and constitutionally small fetuses. In this study,
we sought to characterize PlGF in pregnancies complicated by placental
IUGR compared with pregnancies having constitutionally small fetuses and
uncomplicated pregnancies. We tested
the hypothesis that a positive PlGF test
(low PlGF in maternal circulation) as
measured on a new point-of-care rapid
assay differentiates fetuses with placental IUGR from constitutionally
small fetuses.
163.e2

www.AJOG.org
M ATERIALS AND M ETHODS
Study population
In this retrospective case-control study,
blood samples were prospectively collected from women with singleton pregnancies diagnosed antenatally with IUGR
following written informed consent, between November 2004 and August 2007 at
BC Womens Hospital in Vancouver, Canada. Ethics approval was granted by the
University of British Columbia Childrens
and Womens Health Centre Research
Ethics Boards. Other data pertaining to
this cohort of women have previously been
published.19-22 Eligible women were consecutively recruited from inpatient and
outpatient services at BC Womens Hospital. Women were excluded if they were in
active labor at the time of eligibility or were
within 48 hours of antenatal betamethasone administration.
The antenatal diagnosis of IUGR was
defined as fetal AC less than the 10th percentile for gestational age identified by
antenatal ultrasound. Maternal blood
samples were collected at this time but
were not included into the study until
after delivery. Inclusion required either
birth weight less than the fifth percentile
for gestational age at delivery and sex23
or birthweight less than the 10th percentile with either uterine artery Doppler
notching at 220 to 240 weeks gestation, absent/reversed umbilical artery
end diastolic flow, or oligohydramnios
(amniotic fluid index 50 mm) documented during pregnancy.23
A total of 19 confirmed low-birthweight cases were recruited. Two were
excluded from the primary analysis because of IUGR being attributed to fetal
congenital anomalies confirmed at delivery (one Treachers-Collins syndrome,
one Cornelia de Lange syndrome). One
additional case was excluded because of
IUGR of unknown origin. During this
pregnancy, the women had an appendectomy at 10 weeks gestation, followed
by cerclage for cervical incompetence at
12 weeks. Preterm spontaneous rupture
of membranes occurred at 292 weeks
followed by the delivery of a live fetus 3
weeks later (birthweight less than the
10th percentile). Placenta pathology
showed chorioamnionitis and funisitis

American Journal of Obstetrics & Gynecology FEBRUARY 2012

but no evidence of abnormal placentation. No infection was noted.

The remaining 16 cases were subgrouped based on the presence or absence of placental IUGR. Placental IUGR
(n 9) was defined as IUGR with an
abnormal placental pathology report.
Abnormal placenta pathology included
decidual necrosis, adherent thrombus,
low placental weight, fibrin deposition, fetal surface vessel thrombosis, decreased fetal vascularization, decidual vasculopathy,
calcification, infarcts, intervillous thrombus, and advanced/delayed villous maturation and villitis.
A constitutionally small fetus (n 7)
was defined as a fetus clinically diagnosed antenatally with IUGR and with a
normal placental pathology report. Although not included in the primary analysis, the 3 syndromic IUGR cases all had
normal placental pathology reports. Placental pathology status was determined by
a perinatologist blinded to all aspects of the
womans history, pregnancy course, and
pregnancy outcomes.
A total of 79 non-smoking women
served as normal pregnancy controls.
These women had no documented concerns of hypertension, proteinuria, gestational diabetes or IUGR during their
pregnancy. Normal pregnancy controls
were matched for maternal age (5
years), gestational age (2 weeks), and
parity (0, 1, 2).

Sample collection and PlGF analysis

Maternal venous blood was collected antenatally in EDTA tubes in the standard
fashion. Plasma was obtained through
centrifugation and samples were frozen
at 80C. Laboratory staff was blinded to
the clinical diagnosis of all women. Samples were analyzed for PlGF using the automated Triage PlGF assay kit (Alere San
Diego, San Diego, CA) according to the
product insert. This immunoassay uses
fluorescently labeed murine monoclonal
antibodies against PlGF for PlGF quantification.24-26 Briefly, plasma is thawed
to room temperature and mixed by inversion. A total of 250 L of thawed
plasma is pipetted into the sample port
of a PlGF test cartridge. The cartridge is
inserted into the Triage meter. The results are displayed on the meter in ap-

Obstetrics

www.AJOG.org
proximately 15 minutes in picograms
per milliliter.
The cartridge contains chemistries for
on-board positive and negative control
systems. Control systems at the level of
the cartridge and meter ensure that the
quantitative PlGF result is valid. Calibration information is supplied by the manufacturer in the form of a lot-specific
EPROM chip that is contained within
each kit of devices. The measurable range
of the assay is 123000 pg/mL. Concentrations less than 12 pg/mL are value assigned based on the calibration curve,
but this value is displayed to the user as a
qualitative result less than 12 pg/mL. A
positive test was defined as a PlGF concentration below the fifth percentile for
gestational age of normal controls, as described in the product insert and derived
from Knudsen et al.25
Samples were batch assayed to minimize any effect of interassay variability.

Statistics
Data were analyzed using Prism 4.0
(GraphPad, San Diego, CA). Descriptive
data are expressed as median and interquartile range (IQR) for nonnormally
distributed data. A 2 or Fishers exact
test was used for the comparison of
categorical variables. A Kruskal-Wallis
analysis of variance or Mann-Whitney U
test was used for continuous variables.
The primary outcome of a positive test
identifying placental IUGR was evaluated
using a 2 3 contingency table (positive
vs negative tests for each group) and a
test of association (the Freeman-Halton
test for the complete 2 3 table and
the Fisher exact test of the relevant
2 2 subtable). Sensitivity, specificity,
positive predictive values (PPVs) and negative predictive values (NPVs) for a positive PlGF test identifying placental IUGR
from constitutionally small fetuses were
calculated with 95% confidence intervals
as a secondary analysis. We performed this
analysis with and without the 3 syndromic
IUGR cases excluded from the primary
analysis.
PPV and NPV were calculated to characterize the 2 2 tables, despite the artificial prevalence in this case-control
study. Also, qualitative PlGF results less
than 12 pg/mL were set equal to 12

pg/mL for the purpose of statistical analysis. This approximation does not affect
the reported test performance in terms
of clinical sensitivity, or specificity, but
may slightly underreport the significance
of the difference between groups in the
Kruskal-Wallis analysis.
Differences with P .05 were judged
to be statistically significant. The STARD
(Standards for Reporting of Diagnostic
Accuracy) Initiative guidelines were consulted throughout the design and analysis
of this study.27

R ESULTS
Clinical characteristics
Baseline and outcomes characteristics
of women having fetuses with placental
IUGR, women with constitutionally
small fetuses, and normal pregnancy
controls are shown in Table 1. Matching
criteria between all groups did not differ,
although sampling in women with placental IUGR tended to occur earlier in
gestation (P .04). Parity did not vary
between the groups, and all women had
singleton pregnancies and were normotensive at the time of booking. No
women were smokers at the time of sampling. One woman in the constitutionally small group reported smoking at the
time of conception but had ceased smoking by 8 weeks gestation. Gestational age
at delivery was earlier in the placental
IUGR group. Preterm delivery, SGA status, lower infant birthweights, and intrauterine fetal demise were more common
in the placental IUGR group as well.
In terms of ultrasound parameters,
there were more cases with absent or reversed end diastolic flow at the time of
sampling in fetuses with placental IUGR,
although this difference was not statistically significant. At the time of sampling,
the median percentiles of fetal AC and
femur length (FL) were lower in the placental IUGR group. Apart from the AC
percentile, there were no statistically significant differences in the worst percentile measurements of head circumference, biparietal diameter, amniotic fluid
index, or FL between the groups, although there was a trend for median percentiles to be lower in the placental
IUGR group.

Research

Plasma PlGF
All 9 of the placental IUGR cases had
PlGF levels below the detection limit of
the assay (12 pg/mL). One woman
with a constitutionally small fetus and 2
normal pregnant controls had PlGF concentrations less than 12 pg/mL. Women
with placental IUGR had a median plasma
PlGF concentration of 12.0 pg/mL (12.0,
12.0). Women with constitutionally small
fetuses had a median concentration of 84.4
pg/mL (16.4, 156.5), and normal pregnant
women had a median concentration of 197
pg/mL (89.0, 449.0). Differences between
the 3 groups were statistically significant
(P .001 for each group).
PlGF concentrations for cases and
controls at the time of sampling are
shown in the Figure. All women with
placental IUGR (n 9) had PlGF concentrations below the fifth percentile
cutoff for gestational age in normal
pregnancy and were differentiated
from the normal pregnant controls. All
women with constitutionally small fetuses (n 6) had PlGF concentrations
above the fifth percentile cutoff except
for 1 woman who was sampled at 344
weeks gestation (corresponding to a
false-positive test result). Four normal
pregnancy controls had PlGF concentrations below the fifth percentile cutoff and
were sampled at 265, 335, 361, and
364 weeks gestation (corresponding to a
false-positive test results). The remaining
75 normal controls had PlGF concentrations above the cutoffs.
Although not included in the Figure,
the 3 cases of syndromic IUGR all had
PlGF concentrations within normal
pregnancy ranges (192.9 pg/mL sampled
at 34.7 weeks, 350.1 pg/mL sampled at
35.0 weeks, and 329.5 pg/mL sampled at
29 weeks).
Identification of placental IUGR
The primary outcome of a positive test
differentiating between placental
IUGR, constitutionally small fetuses,
and normal pregnancy is shown in Table 2. All 9 women with placental IUGR
had a positive test result. One woman
with a constitutionally small fetus and
4 women with normal pregnancy had
positive PlGF test results. The differences between the groups of the 2 3

FEBRUARY 2012 American Journal of Obstetrics & Gynecology

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TABLE 1

Maternal and perinatal baseline and outcome characteristics of the study groups
Characteristic

Placenta IUGR (n 9)

Constitutionally small
fetuses (n 7)

Normal pregnancy
control (n 79)

P value
(2 or KW)

Baseline

.......................................................................................................................................................................................................................................................................................................................................................................

Maternal age, y

34 [2839]

32 [2636]

33 [3135]

.8

GA at sampling, wks

24.6 [23.033.3]

34.0 [24.636.6]

33.0 [31.035.0]

.04

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Nulliprous, %

4 (44)

5 (71)

52 (66)

.4

Singleton pregnancy, %

9 (100)

8 (100)

79 (100)

1.0

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

sBP at booking, mm Hg

118 [108125]

110 [100120]

115 [108120]

.7

dBP at booking, mm Hg

70 [6077]

70 [7074]

70 [7080]

.4

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
a

Smoking at sampling, %

0 (0)

0 (0)

0 (0)

................................................................................................................................................................................................................................................................................................................................................................................

Ultrasound

.......................................................................................................................................................................................................................................................................................................................................................................
b

Absent or reversed EDF at sampling, %

3 (33)

0 (0) (n 6)

0.1

Uterine artery notching

3 (60) (n 5)

1 (25) (n 4)

0.3

AC percentile at sampling, %

1 [14]

5 [39]

0.02

Worst AC percentile, %

1 [13]

2 [24]

.01

FL percentile at sampling, %

1 [14]

12 [434]

.005

Worst FL percentile, %

1 [14]

4 [216]

.07

BPD percentile at sampling, %

4 [115]

6 [416]

.5

Worst BPD percentile, %

1 [17]

4 [16]

.5

20 [338]

.1

4 [124]

.2

.4

.7

.......................................................................................................................................................................................................................................................................................................................................................................
b
.......................................................................................................................................................................................................................................................................................................................................................................
b
.......................................................................................................................................................................................................................................................................................................................................................................
b
.......................................................................................................................................................................................................................................................................................................................................................................
b
.......................................................................................................................................................................................................................................................................................................................................................................
b
.......................................................................................................................................................................................................................................................................................................................................................................
b
.......................................................................................................................................................................................................................................................................................................................................................................
b
.......................................................................................................................................................................................................................................................................................................................................................................
b

HC percentile at sampling, %

10 [115]

.......................................................................................................................................................................................................................................................................................................................................................................
b

Worst HC percentile, %

1 [16]

.......................................................................................................................................................................................................................................................................................................................................................................
b

18 [341] (n 8)

AFI percentile at sampling, %

20 [453] (n 6)

.......................................................................................................................................................................................................................................................................................................................................................................
b

Worst AFI percentile, %

3 [2.528]

9 [321]

................................................................................................................................................................................................................................................................................................................................................................................

Outcome

.......................................................................................................................................................................................................................................................................................................................................................................

GA at delivery, wks

30.6 [24.934.7]

37.6 [37.438.5]

39.7 [38.340.3]

.0001

.......................................................................................................................................................................................................................................................................................................................................................................

Preterm delivery, %

8 (89)

2 (29)

.0001

1 (1)

.......................................................................................................................................................................................................................................................................................................................................................................

Birthweight, g

1050 [4301568]

2182 [20902480]

3493 [31503758]

.0001

.......................................................................................................................................................................................................................................................................................................................................................................

.0001

SGA less than third percentile, %

7 (78)

4 (50)

0 (0)

Cord pH

7.25 [7.257.30]

7.29 [7.247.31]

7.23 [7.177.28]

.1

2.9 [5.2 to 0.7]

4.5 [6.3 to 2.5]

6.0 [7.7 to 4.5]

.03

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Base deficit

.......................................................................................................................................................................................................................................................................................................................................................................

.0001

Intrauterine fetal demise, %

4 (44)

0 (0)

0 (0)

Neonatal death, %

0 (0)

0 (0)

0 (0)

Abnormal placental pathology, %

9 (100)

0 (0)

0 (0)(n 11)

.......................................................................................................................................................................................................................................................................................................................................................................

1.0

.......................................................................................................................................................................................................................................................................................................................................................................

.0001

................................................................................................................................................................................................................................................................................................................................................................................
23

SGA was achieved if any fetus was born less than the third percentile for gestational age at delivery and sex using multiethnic Canadian birthweight charts. Data are expressed as median
[interquartile range] or n (%).
AFI, amniotic fluid index; BPD, biparietal diameter; dBP, diastolic blood pressure; EDF, end diastolic flow; GA, gestational age; HC, head circumference; IUGR, intrauterine growth restriction; KW,
Kruskal-Wallis analysis of variance; sBP, systolic blood pressure.
a

One woman was smoking at the time of conception but had completely ceased smoking by until 8 weeks gestation; b Fishers exact test or Mann-Whitney U test.

Benton. PlGF in placental IUGR. Am J Obstet Gynecol 2012.

contingency table was statistically significant (P .0001) as expected because this is driven by the large group
of normal pregnancy controls.
163.e4

The test performance of PlGF differentiating between placental IUGR and

constitutionally small fetuses is shown in
Table 3. Sensitivity and specificity was

American Journal of Obstetrics & Gynecology FEBRUARY 2012

100% (66, 100) and 86% (42, 100), respectively. The difference between the 2
groups was statistically significant (P
.0009).

Obstetrics

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FIGURE

Maternal PlGF concentrations in study groups

Normal pregnancy
Placental IUGR
Constitutionally small fetuses

10000

Log 10 PlGF concentration

In a subanalysis, we combined the

constitutionally small fetuses and the 3
syndromic IUGR cases to create a nonplacental group and performed a sensitivity and specificity analysis. The 3 cases
of syndromic IUGR were counted as true
negative results because all had normal
PlGF concentrations with normal placental pathology. The sensitivity of PlGF to
differentiate placental IUGR from nonplacental IUGR/constitutionally small fetuses
remained the same, whereas specificity increased to 90% (56, 100) (Table 3).

Research

1000

100

C OMMENT
We have shown that PlGF levels in maternal circulation may have the potential
to identify placental IUGR antenatally. A
positive PlGF test result on the automated Triage PlGF assay (concentration
below the fifth percentile for gestational
age for a normal pregnancy) (Alere San
Diego) was more common in women
with placental IUGR than women with
constitutionally small fetuses or normal
pregnancies. We have also shown that a
positive PlGF test identifies placental
IUGR from constitutionally small fetuses with high sensitivity and specificity.
Our results agree with previous reports of lowered PlGF concentrations in
maternal circulation of women with
growth-restricted fetuses.13,17,18,28 From
the Figure, it is possible to see the differentiation in PlGF levels between placental IUGR and normal pregnancies as
well as pregnancies with constitutionally small fetuses. Previous studies have
not investigated PlGF levels and placental IUGR nor looked at it in isolation
from preeclampsia, another obstetric
complication with placental implications. We believe that by grouping
women with fetuses with placental IUGR
and comparing them with women with
constitutionally small fetuses, the true
usefulness of PlGF, its ability to identify
growth restriction because of a pathological placenta, is demonstrated.
Because it is challenging to diagnose placental IUGR prior to delivery, a readily
available marker, such as one in maternal
circulation, could help to stratify these fetuses into high- and low-risk groups. The
relationship between placental dysfunc-

10

20

22

24

26

28

30

32

34

36

38

40

42

Gestational age at sampling (w)

PlGF concentrations in the circulation of women with placental IUGR fetuses, constitutionally small
fetuses, and normal pregnancies at the time of sampling. Constitutionally small fetuses (red triangles)
and normal pregnancy controls (black squares) had increased PlGF levels compared with placental
IUGR cases (blue triangles). The gray dashed black line represents the fifth percentile PlGF concentration cutoff according to the product insert. The y-axis is log transformed. Two blue triangles overlap
at 332 weeks gestation because of the sampling of these women occurring at the same gestational
age.
IUGR, intrauterine growth restriction; PlGF, placental growth factor.
Benton. PlGF in placental IUGR. Am J Obstet Gynecol 2012.

tion, IUGR, and low PlGF concentrations

may allow clinicians to utilize PlGF as a diagnostic tool in conjunction with standard
surveillance technologies already used in
clinical practice.29-31 A diagnostic test,
such as PlGF, to identify women with placental IUGR would modify clinical care
(surveillance and timely interventions), reducing anxiety for patients not affected by

placental disease and focusing efforts on

those who are affected.
Discriminating between growth restriction because of placental origin and
other causes such as infection, aneuploidy, and fetal syndromes is also clinically important. In the 3 women excluded from the primary outcome
analysis because of syndromic IUGR, all

TABLE 2

PlGF test results from women with placental IUGR, constitutionally

small fetuses, and normal pregnancies

Test result

Placental IUGR
(n 9)

Constitutionally
small fetuses
(n 7)

Positive

Negative

75

Normal pregnancy
(n 79)

P value
.0001

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

A positive PlGF result is defined as a PlGF concentration below the fifth percentile for gestational age at sampling for
normal pregnancy, as described in the product insert. The P value is from a Freeman-Halton test (extension of Fisher
exact) of the 2 3 table.
IUGR, intrauterine growth restriction; PlGF, placental growth factor.
Benton. PlGF in placental IUGR. Am J Obstet Gynecol 2012.

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TABLE 3

Sensitivity and specificity of PlGF to identify placental IUGR from constitutionally

small fetuses or nonplacental IUGR/constitutionally small fetuses
Sensitivity
(95% CI)

Specificity
(95% CI)

PPV
(95% CI)

NPV
(95% CI)

P value

Placental IUGR from constitutionally small fetuses

(n 16)

100 (66100)

86 (42100)

90 (56100)

100 (54100)

.0009

Placental IUGR from nonplacental IUGR/

constitutionally small fetuses (n 19)

100 (66100)

Variable

................................................................................................................................................................................................................................................................................................................................................................................

90 (56100)

90 (56100)

100 (66100)

.0001

................................................................................................................................................................................................................................................................................................................................................................................

A positive PlGF result is defined as a PlGF concentration below the fifth percentile for gestational age at sampling for normal pregnancy, as described in the product insert. The P value is from a Fisher
exact test of the 2 2 table.
CI, confidence interval; IUGR, intrauterine growth restriction; NPV, negative predictive value; PlGF, placental growth factor; PPV, positive predictive value.
Benton. PlGF in placental IUGR. Am J Obstet Gynecol 2012.

women had PlGF concentrations in the

normal pregnancy ranges. In these cases,
all PlGF concentrations were above the
fifth percentile for gestational age, and
these women tested negative for placental IUGR (data not shown). When these
cases were combined with constitutionally small fetuses in a secondary analysis
(Table 3), specificity of the assay increased slightly.
Although preliminary, these results
suggest that PlGF may have the ability to
differentiate constitutionally small fetuses from those with not only placental
IUGR but also syndromic IUGR from
placental IUGR (ie, placental vs nonplacental). In this regard, the PlGF test may
identify the impaired placentation of
placental IUGR.
Our normal pregnancy values confirm
those previously reported by Knudsen et
al.25 Normal pregnancy concentrations
follow the previously reported PlGF
changes during pregnancy: a gradual increase up until about 33 weeks with a subsequent decrease until delivery.12-15 We
have also, for the first time, observed this
pattern in PlGF concentrations in women
with constitutionally small fetuses.
Because these fetuses are healthy but
small, we would assume the placenta is
properly formed and functioning well.
This would explain the similar concentrations seen between their values and
those of a normal pregnancy. One of our
women with a constitutionally small fetus had a PlGF concentration below the
fifth percentile and a subsequent falsepositive PlGF test result. There were also
4 false-positive results in the normal
pregnancy control group. The diagnostic
163.e6

performance of this assay begins to decrease after 350 weeks gestation in preeclampsia, as described in the product
insert. The natural decline in PlGF at or
near term may explain the positive results for these cases because they clearly
did not have placental IUGR.
Results from this study need to be
confirmed in a larger, prospective cohort study of women with fetuses suspected to have IUGR. An investigation
into this group of women would better
elucidate the ability of PlGF to identify
the pathological placenta. It is unlikely
that PlGF could serve as a definitive diagnostic test for placental IUGR. In
practice, PlGF would need to be used in
conjunction with other laboratory and
clinical technologies such as uterine
and umbilical artery Dopplers. Although Doppler studies are inconsistent and not recommended for routine
screening, Doppler could be used in
conjunction with a positive PlGF test
to confirm the diagnosis of placental
IUGR, thereby improving the ability
to correctly identify high-risk patients.29-32
Further investigations into the concurrent
use of technologies such as artery Doppler
and PlGF are needed because we do not
have Doppler results for our groups of
women.
Overall, although this study has a
small sample size, it does provide compelling preliminary data for further investigation into PlGF in IUGR. Because
the method for detecting PlGF in maternal circulation has advanced to point-ofcare testing, in which results can be available in a timely fashion, integration into

American Journal of Obstetrics & Gynecology FEBRUARY 2012

routine clinical practice after validation

in a larger cohort appears feasible.

C ONCLUSION
Our preliminary data suggest that PlGF
measured on the Triage assay (Alere San
Diego) differentiates placental IUGR
from constitutionally small fetuses with
high sensitivity and specificity. Further
studies are needed to support PlGF as a
useful biomarker in the identification of
placental IUGR.

Use of statistics
Data were analyzed using Prism 4.0
(GraphPad). Descriptive data are expressed as median and IQR for nonnormally distributed data. 2 tests were
used for comparison of categorical
variables. A Kruskal-Wallis analysis of
variance was used for continuous variables. The primary outcome of a positive test identifying placental IUGR
was evaluated using a 2 3 contingency table (positive vs negative tests
for each group) and a test of association (the Freeman-Halton test for the
complete 2 3 table and the Fisher
exact test of the relevant 2 2 subtable). Sensitivity, specificity, PPVs,
and NPVs for a positive PlGF test identifying placental IUGR were calculated
with 95% confidence intervals. PPVs
and NPVs were calculated to characterize the 2 2 tables, despite the artificial prevalence in this case-control
study.
f
ACKNOWLEDGMENTS
Direct research assistance was received from
Pamela Lutley, Tara Morris, Cline Basque, and

Obstetrics

www.AJOG.org
Monica Pearson. We gratefully acknowledge
the support of Dr David P. Speert with the original funding application and study design and Dr
Jennifer Hutcheon for her statistical input.

REFERENCES
1. Bryan SM, Hindmarsh PC. Normal and abnormal fetal growth. Horm Res 2006;65(Suppl
3):19-27.
2. Engineer N, Kumar S. Perinatal variables and
neonatal outcomes in severely growth restricted preterm fetuses. Acta Obstet Gynecol
Scand 2010;89:1174-81.
3. Garite TJ, Clark R, Thorp JA. Intrauterine
growth restriction increased morbidity and mortality among premature neonates. Am J Obstet
Gynecol 2004;191:481-7.
4. Bassan H, Stolar O, Geva R, et al. Intrauterine
growth-restricted neonates born at term or preterm: how different? Pediatr Neurol 2011;44:
122-30.
5. Roberts D, Post M. The placenta in preeclampsia and IUGR. J Clin Pathol 2008;61:
1254-60.
6. Salafia C. Placental pathology of fetal growth
restriction. Clin Obstet Gynecol 1997;40:740-9.
7. Khong T, de Wolf F, Robertson W, Brosens
I. Inadequate maternal vascular response to
placentation in pregnancies complicated by
pre-eclampsia and by small-for-gestational
age infants. Br J Obstet Gynaecol 1986;93:
1049-59.
8. Egbor M, Ansari T, Morris N, Green C, Sibbons P. Morphometric placental villous and
vascular abnormalities in early- and late-onset
pre-eclampsia with and without fetal growth restriction. Br J Obstet Gynaecol 2006;113:
580-9.
9. Halliday HL. Neonatal management and
long-term sequelae. Best Pract Res Clin Obstet
2009;23:871-80.
10. Baker DJP. The developmental origins of
well-being. Phil Trans R Soc Lond 2004;359:
1359-66.
11. Clark D, Smith S, Licence D, Evans A, Charnock-Jones D. Comparison of expression patterns for placental growth factor, vascular endothelial growth factor (VEGF), VEGF-B, and
VEGF-C in the human placenta throughout gestation. J Endocrinol 1998;159:459-67.
12. Makrydimas G, Sotiriadis A, Savvidou M,
Spencer K, Nicolaides K. Physiological distribu-

tion of placental growth factor and soluble Flt-1

in early pregnancy. Prenat Diagn 2008;28:
175-9.
13. Levine R, Maynard S, Qian C, et al. Circulating angiogenic factors and the risk of preeclampsia. N Engl J Med 2004;350:672-82.
14. Levine R, Lam C, Qian C, et al. Soluble endoglin and other circulating antiangiogenic factors in preeclampsia. N Engl J Med 2006;355:
992-1005.
15. Maynard S, Min J, Merchan J, et al. Excess
placental soluble fms-like tyrosine kinase 1
(sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in preeclampsia. J Clin Invest 2003;111:649-58.
16. Buhimschi C, Baumbusch M, Dulay A, et al.
The role of urinary solunle endoglin in the diagnosis of pre-eclampsia: comparison with soluble fms-like tyrosine kinase 1 to placental
growth factor ratio. BJOG 2010;117:321-30.
17. Taylor R, Grimwood J, Taylor R, McMaster
M, Fisher S, North R. Longitudinal serum concentrations of placental growth factor: evidence
for abnormal placental angiogenesis in pathologic pregnancies. Am J Obstet Gynecol 2003;
188:177-82.
18. Romero R, Nien J, Espinoza J, et al. A longitudinal study of angiogenic (placental growth
factor) and anti-angiogenic (soluble endoglin
and soluble vascular endothelial growth factor
receptor-1) factors in normal pregnancy and
patients destined to develop preeclampsia and
deliver a small for gestational neonate. J Matern
Fetal Neonatal Med 2008;21:9-23.
19. Xie F, Hu Y, Turvey S, et al. Toll-like receptors 2 and 4 and the cryopyrin inflammasome in
normal pregnancy and pre-eclampsia. BJOG
2010;117:99-108.
20. Xie F, Hu Y, Krajden M, et al. An association
between cytomegalovirus infection and preeclampsia: case-control study and data synthesis. Acta Obstet Gynecol Scand 2010;89:
1162-7.
21. Xie F, Hu Y, Speert DP, et al. Toll-like receptor gene polymorphisms and preeclampsia risk:
a case-control study and data synthesis. Hypertens Pregnancy 2010;29:390-8.
22. Xie F, Hu Y, Magee LA, et al. Chlamydia
pneumoniae infection in preeclampsia. Hypertens Pregnancy 2010;29:268-77.
23. Kramer M, Platt R, Wen S, Joseph K, Allen
A, Abrahamowicz M. A new and improved population-bases Canadian reference for birth

Research

weight for gestational age. Pediatrics 2001;

108:E35.
24. Redman C, Lodge T, Meacher H, Marks C,
Simms C, Sargent I. Triage PlGF test: point-ofcare assay of plasma placental growth factor to
diagnose preeclampsia. Adv Perinat Med 2010;
Proceedings(ECPM):181-5.
25. Knudsen UB, Kronborg CS, von Dadelszen
P, et al. A single rapid point-of-care placental
growth factor determination as an aid to the
diagnosis of preeclampsia. Preg Hypertens
2011 Oct. 5 [Epub ahead of print] doi:10.1016/
j.pregh.2011.08.117.
26. Benton SJ, Hu Y, Xie F, et al. Angiogenic
factors as diagnostic tests for preeclampsia: a
performance comparison between two commercial immunoassays. Am J Obstet Gynecol
2011 Jun 21 [Epub ahead of print] doi:10.1016/
j.ajog.2011.06.058.
27. Bossuyt PM, Reitsma JB, Bruns DE, et al.
Towards complete and accurate reporting of
studies of diagnostic accuracy: the STARD initiative. Clin Chem 2003;49:1-6.
28. Poon L, Zaragoza E, Akolekar R, Anagnostopoulos E, Nicolaides K. Maternal serum placental growth factor (PlGF) in small for gestational age pregnancy at 110 to 130 weeks of
gestation. Prenat Diagn 2008;28:1110-5.
29. Welch P, Amankwah K, Miller P, McAsey M,
Torry D. Correlations of placental perfusion and
PlGF protein expression in early human pregnancy. Am J Obstet Gynecol 2006;194:
1625-31.
30. Crispi F, Dominguez C, Llurba E, MartinGallan P, Cabero L, Gratacos E. Placental angiogenic growth factors and uterine artery
doppler findings for characterization of different
subsets in preeclampsia and in isolated intrauterine growth restriction. Am J Obstet Gynecol
2006;195:201-7.
31. Crispi F, Llurba E, Dominguez C, MartinGallan P, Cabero L, Gratacos E. Predictive
value of angiogenic factors and uterine artery
Doppler for ealry- versus late-onset pre-eclampsia and intrauterine growth restriction. Ultrasound Obstet Gynecol 2008;31:303-9.
32. Espinoza J, Romero R, Nien J, et al. Identificatioin of patients at risk for early and/or severe
preeclampsia with the use of uterine artery
Doppler velocimetry and placental growth factor. Am J Obstet Gynecol 2007;326:e1-13.

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163.e7