Angela Ramoni

Analysis of Aberrant DNA Methylation and Human Papillomavirus DNA in Cervicovaginal Specimens to Detect Invasive Cervical Cancer and Its Precursors

Purpose: Cancer of the uterine cervix is an important cause of death in women worldwide. Pap smears as a tool for screening decreased the incidence and mortality of cervical cancer dramatically. This proof of principle study aimed to develop a potential tool for cervical screening using a test that can be applied by patients without visiting a physician and to increase the coverage rate, especially of the high-risk population with low socioeconomic status. Experimental Design: Human papillomavirus (HPV) DNA testing and methylation analysis of DNA obtained from cervicovaginal specimens of 13, 31, and 11 patients with no dysplasia/low-grade squamous intraepithelial lesion (SIL), high-grade SIL, and invasive cervical cancer, respectively, collected on a tampon, was performed using PCR-based methods to detect invasive cervical cancer and study whether these changes are already present in the precursor lesions. Results: High-risk HPV DNA was present in 68 and 82% of patients with high-grade SIL and invasive cervical cancer. DNA methylation of the 11 genes tested increased with severity of the cervical lesion. Unsupervised hierarchical cluster analysis using solely information on DNA methylation of the 11 genes was able to predict the presence of invasive cervical cancers: one of the two clusters formed contained 9 of 11 invasive cervical cancers, as well as two high-grade SILs. Conclusions: HPV DNA and DNA methylation analyzed in cervicovaginal specimens are able to predict invasive cervical cancers. To detect all high-grade SILs when applying this test, genes that become methylated earlier throughout cervical carcinogenesis have to be defined.

Implementation of the sFlt-1/PlGF ratio for prediction and diagnosis of pre-eclampsia in singleton pregnancy: implications for clinical practice

Pre-eclampsia (PE) is a leading cause of maternal and fetal/neonatal morbidity and mortality worldwide. Clinical diagnosis and definition of PE is commonly based on the measurement of non-specific signs and symptoms, principally hypertension and proteinuria1–3. However, due to the recognition that measurement of proteinuria is prone to inaccuracies and the fact that PE complications often occur before proteinuria becomes significant, most recent guidelines also support the diagnosis of PE on the basis of hypertension and signs of maternal organ dysfunction other than proteinuria3–5. Furthermore, the clinical presentation and course of PE is variable, ranging from severe and rapidly progressing early-onset PE, necessitating preterm delivery, to late-onset PE at term. There may be associated intrauterine growth restriction (IUGR), further increasing neonatal morbidity and mortality. These features suggest that the classical standards for the diagnosis of PE are not sufficient to encompass the complexity of the syndrome. Undoubtedly, proper management of pregnant women at high risk for PE necessitates early and reliable detection and intensified monitoring, with referral to specialized perinatal care centers, to reduce substantially maternal, fetal and neonatal morbidity6,7. In the decade since Maynard et al.8 reported that excessive placental production of soluble fms-like tyrosine kinase receptor-1 (sFlt-1), an antagonist of vascular endothelial growth factor and placental growth factor (PlGF), contributes to the pathogenesis of PE, extensive research has been published demonstrating the usefulness of angiogenic markers in both diagnosis and the subsequent prediction and management of PE and placenta-related disorders. Various reports have demonstrated that disturbances in angiogenic and antiangiogenic factors are implicated in the pathogenesis of PE and have possible relevance in the diagnosis and prognosis of the disease. Increased serum levels of sFlt-1 and decreased levels of PlGF, thereby resulting in an increased sFlt-1/PlGF ratio, can be detected in the second half of pregnancy in women diagnosed to have not only PE but also IUGR or stillbirth, i.e. placenta-related disorders. These alterations are more pronounced in early-onset rather than late-onset disease and are associated with severity of the clinical disorder. Moreover, the disturbances in angiogenic factors are reported to be detectable prior to the onset of clinical symptoms (disease), thereby allowing discrimination of women with normal pregnancies from those at high risk for developing pregnancy complications, primarily PE9–30. Plasma concentrations of angiogenic/antiangiogenic factors are of prognostic value in obstetric triage: similar to the progressively worsening clinical course observed in women with early-onset PE, changes in the angiogenic profile leading to a more antiangiogenic state can be found. Current definitions of PE are poor in predicting PE-related adverse outcomes. A diagnosis of PE based on blood pressure and proteinuria has a positive predictive value of approximately 30% for predicting PE-related adverse outcomes31. Estimation of the sFlt-1/PlGF ratio allows identification of women at high risk for imminent delivery and adverse maternal and neonatal outcome23,30,32–35. Moreover, it has also been shown that the time-dependent slope of the sFlt-1/PlGF ratio between repeated measurements is predictive for pregnancy outcome and the risk of developing PE, and repeated measurements have been suggested36. However, the ‘optimal’ time interval for a follow-up test remains unclear. Finally, high values are closely related to the need to deliver immediately22,23,37. Additionally, in normal and complicated pregnancies, angiogenic factors are correlated with Doppler ultrasound parameters, mainly uterine artery (UtA) indices38–42. Combining the sFlt-1/PlGF ratio with UtA Doppler ultrasound, at the time of diagnosis of early-onset PE, has prognostic value mainly for perinatal complications, being limited for the prediction of maternal complications37,43. The additional measurement of the sFlt-1/PlGF ratio has been shown to improve the sensitivity and specificity of Doppler measurement in predicting PE44–48, supporting its implementation in screening algorithms. Whereas studies on the predictive efficacy of the sFlt-1/PlGF ratio in the first trimester have yielded contradictory results49, reports on the use of this marker as an aid in prediction from the mid trimester onwards have led to its suggested use as a screening tool, especially for identifying all women developing PE and requiring delivery within the subsequent 4 weeks50–52. This short review of the literature highlights that measurement of the sFlt-1/PlGF ratio has the potential to become an additional tool in the management of PE, particularly as automated tests that allow rapid and easy measurement of these markers are now widely available. Nevertheless, although these markers were incorporated recently into the German guidelines53, no formal recommendation regarding how to use sFlt-1, PlGF or the sFlt-1/PlGF ratio has been established in any official protocol. The purpose of this paper is to answer questions that are frequently asked around the use of the sFlt-1/PlGF ratio in the diagnosis and prediction of PE and regarding the implications for clinical practice, in particular, ‘When?’ and ‘In which women?’ should the sFlt-1/PlGF ratio be measured and, ‘What should be done with the results?’, and to provide guidance to educate physicians on the use of the sFlt-1/PlGF ratio in clinical practice. To achieve this, international experts in the use of angiogenic markers have strived to develop a consensus statement on the clinical use of the sFlt-1/PlGF ratio and the consequential management in pregnant women with suspected PE or at a high risk of developing PE.

Left ventricular function many years after recovery from pre-eclampsia.

Please cite this paper as: Strobl I, Windbichler G, Strasak A, Weiskopf‐Schwendinger V, Schweigmann U, Ramoni A, Scheier M. Left ventricular function many years after recovery from pre‐eclampsia. BJOG 2011;118:76–83.

Conservative management of abnormally invasive placenta: four case reports

Prenatal diagnosis of placenta increta and percreta is essential to avoid potentially life‐threatening hemorrhage by optimizing peripartal management. Invasive placentation presents significant challenges at cesarean section even for highly skilled surgeons. In the four cases of placenta increta/percreta presented here we tried to avoid hysterectomy by leaving the placenta behind and tried to accelerate regression of placental tissue by administering methotrexate. The outcome in each of the four women was different, but no major bleeding occurred in any of the cases. Close follow‐up for many weeks is mandatory.

Congenital Fibrosarcoma as Cause for Fetal Anemia: Prenatal Diagnosis and in utero Treatment

Objectives: To discuss diagnosis and management of a case of a rare fetal tumor complicated by fetal anemia due to intratumoral hemorrhage. Case Report: We report on a 29-week-old fetus with a tumor in the posterior left shoulder region. The morphologic aspect of the tumor, lack of fetal movements and an increased middle cerebral artery (MCA) peak systolic velocity (PSV) were indicative of fetal anemia caused by intratumoral bleeding. Following intravascular blood transfusion the pregnancy was safely prolonged for 15 days, during which lung maturity was induced. After delivery the neonate underwent surgical excision. Histological examination revealed an infantile congenital fibrosarcoma. Conclusion: Anemia must be ruled out in cases with fetal tumors. MCA PSV is useful in diagnosis and surveillance in these fetuses.

Perinatal mortality and advanced maternal age.

Objective: To investigate the impact of advanced maternal age on the rate of perinatal mortality. Design: Retrospective cohort study including all 56,517 singleton hospital deliveries between 1999 and 2008. Methods: Data were analyzed according to maternal age at delivery in 3 groups of women, 25-34 years, 35-39 years and ≥40 years, using the youngest as the reference group. Results: Odds ratios (ORs) for antenatal deaths were 0.98 (CI: 0.67-1.43) and 2.57 (CI: 1.57-4.22) for age groups 35-39 years and ≥40 years, respectively. Significant differences in neonatal mortality rates between the age groups were not found. Significant amendable risk factors were attendance of <4 health care visits (OR = 15.55, CI: 9.47-25.51 in age group 35-39 years; OR = 16.38, CI: 9.78-27.43 in the age group ≥40 years) and obesity (OR = 1.85, CI: 1.27-2.70 in age group 35-39 years; OR = 1.83, CI: 1.22-2.74 in the age group ≥40 years). In the multivariate regression analysis, the adjusted ORs for perinatal mortality were 1.03 (95% CI: 0.77-1.39) and 1.66 (95% CI: 1.03-2.66) for age groups 35-39 and ≥40, respectively. Conclusions: Women older than 40 years carry an increased risk for stillbirth. Important amendable risk factors are obesity and poor antenatal care.

Impact of nuchal cord on measurement of fetal nuchal translucency thickness

To define the impact of nuchal cord on the measurement of fetal nuchal translucency thickness (NT).