www.ajog.org
Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology,a Departments of Biostatistics,
Bioinformatics, and Epidemiology,b Medical University of South Carolina, Charleston, SC
Received for publication September 14, 2005; revised December 13, 2005; accepted December 22, 2005
KEY WORDS Objective: The purpose of this study was to determine if maternal serum concentrations of pla-
Pregnancy centa growth factor (PlGF) and soluble Fms-like tyrosine kinase 1 receptor (s-Flt1) are more
Preeclampsia abnormal in patients with severe preeclampsia compared with mild preeclampsia.
Placenta growth factor Study design: Serum samples were collected from 32 control patients and 80 patients with mild or
(PlGF) severe preeclampsia. PlGF and s-Flt1 concentrations were quantitated by enzyme-linked immu-
Soluble Fms-like nosorbent assay (ELISA). Results are expressed as median (Q1-Q3) unless stated otherwise. After
tyrosine kinase normalization, serum markers were compared using one-way analysis of covariance (ANCOVA).
1 receptor (s-Flt1) Results: Patients with preeclampsia had decreased levels of PlGF (75.1 G 14 vs 391 G 54 pg/mL,
P ! .0001) and elevated s-Flt1 concentration (1081 G 108 vs 100.1 G 26.9 pg/mL, P ! .0001)
compared with the respective controls (mean G SEM). PlGF concentration was lower in patients
with mild preeclampsia compared with severe, respectively (67 pg/mL [39-158] vs 24 pg/mL [4-57],
P ! .02). s-Flt1 was not different between mild and severe preeclampsia (674 pg/mL [211-1297] vs
1015 pg/mL [731-1948], P = .08).
Conclusion: PlGF and s-Flt1 serum levels are abnormal in patients with preeclampsia com-
pared with controls, but only PlGF is more abnormal in severe preeclampsia compared with mild
preeclampsia.
Ó 2006 Mosby, Inc. All rights reserved.
Supported by National Institutes of Health National Institute of Preeclampsia is a multisystem disorder that occurs
Child Health and Human Development grant number: 5 R03 HD in 5% of all pregnancies and is a major contributor to
41031-02, Institutional Review Board Project # HR 9983. maternal and neonatal morbidity and mortality.1,2 The
Presented at the Twenty-fifth Society of Maternal Fetal Medicine hallmark of the disease is hypertension and proteinuria.
Meeting, Reno, NV, February 7-12, 2005.
The etiology of preeclampsia remains speculative and
* Reprint requests: Donna D. Johnson, MD, Department of
Obstetrics and Gynecology, Medical University of South Carolina,
is most likely multifactorial; however, endothelial dys-
96 Jonathan Lucas St, PO Box 250619, Charleston, SC 29439. function likely contributes to the multisystem organ
E-mail: johnsodo@musc.edu dysfunction.3-6
0002-9378/$ - see front matter Ó 2006 Mosby, Inc. All rights reserved.
doi:10.1016/j.ajog.2005.12.049
256 Robinson et al
Recently, growth factors that activate the endothe- antenatal course. Patients who met the criteria for mild
lium have received attention. Vascular endothelial growth or severe preeclampsia as defined by the American
factor (VEGF) is the most potent stimulant of vascular College of Obstetricians and Gynecologists were en-
endothelium and permeability studied to date.7-9 To rolled.19 Hemolysis, elevated liver enzymes, and low
confer its biological properties, VEGF must covalently platelets (HELLP) syndrome was defined as an aspar-
dimerize before it can bind to its endothelial receptor tate amniotransferase (AST) greater than 70 IU/L
and activate endothelial cells. Two proteins, placenta and platelet count less than 100,000. The definition of
growth factor and soluble fms-like tyrosine kinase 1 re- HELLP syndrome used in this study is limited in
ceptor (s-Flt1), can modulate VEGF biological activity. that peripheral smears were not obtained to support in-
First, VEGF may form a bond with VEGF to form travascular hemolysis. Some authors have defined this
a homodimer or with placenta growth factor (PlGF) as ‘‘partial’’ HELLP syndrome.20 If a history of
to form a heterodimer. VEGF homodimers are much chronic hypertension, collagen vascular disease, multi-
more potent stimulants to the endothelial cells than the ple gestations, renal disease, diabetes, current urinary
VEGF-PlGF heterodimers. In fact, PlGF homodimers tract infection, or tobacco abuse was obtained, the pa-
compete with the same receptors as the more potent tient was excluded. Both controls and patients with ei-
VEGF dimers and only weakly activate endothelial ther mild or severe preeclampsia were enrolled into the
cells.10 Next, VEGF and PlGF may circulate bound to study before spontaneous labor, induction of labor, or
s-Flt1. Only the free VEGF and PlGF is bioavailable.11,12 rupture of fetal membranes. A subanalysis of serum
So, PlGF and s-Flt1 receptor are both important regula- PlGF and s-Flt1 in patients with HELLP syndrome
tors of VEGF biological activity.13,14 was compared with patients with severe preeclampsia.
Whether VEGF serum levels are altered in pree- Whole blood was obtained from participants by
clampsia remains debateable, but the factors that mod- venipuncture and collected in a serum-separator tube.
ulate the biological activity of VEGF are clearly altered. The serum was removed after centrifugation at 10,000
PlGF is significantly decreased in preeclamptic patients RPM for 10 minutes. Serum samples were aliquotted
compared with controls.15-17 S-Flt1 receptor is increased and stored at 70(C for 4 months before assay. Assays
in patients with preeclampsia. The serologic changes in were performed in batches every 4 months.
PlGF and s-Flt1 precede the onset of clinical symp- Quantikine human PlGF and s-Flt1 ELISA (R&D
toms.17,18 The hypothesis to be tested in this study was Systems, Minneapolis, MN) kits were used to measure
that PlGF and s-Flt1 would be more altered in the serum concentrations in duplicate. A microplate reader
maternal serum in patients with severe preeclampsia was utilized to detect the optical density at 450 nm with
compared with mild preeclampsia. optical correction at 540 nm for each serum sample. PlGF
and s-Flt1 concentrations were determined by compari-
Material and methods son to standard curve measurements performed under
identical lab conditions at the time of assay. Concentra-
The Institutional Review Board at the Medical Univer- tions of PlGF and s-Flt1 were reported as picograms per
sity of South Carolina approved this study. Control milliliter. The lab personnel were blinded to the clinical
patients were healthy nonsmokers with an uncomplicated information regarding each subject.
Robinson et al 257
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