Cahit Birdir

Chromosome-selective sequencing of maternal plasma cell-free DNA for first-trimester detection of trisomy 21 and trisomy 18

OBJECTIVE The purpose of this study was to assess the prenatal detection rate of trisomy 21 and 18 and the false-positive rate by chromosome-selective sequencing of maternal plasma cell-free DNA. STUDY DESIGN Nested case-control study of cell-free DNA was examined in plasma that was obtained at 11-13 weeks before chorionic villous sampling from 300 euploid pregnancies, 50 pregnancies with trisomy 21, and 50 pregnancies with trisomy 18. Laboratory personnel were blinded to fetal karyotype. RESULTS Risk scores for trisomy 21 and 18 were given for 397 of the 400 samples that were analyzed. In all 50 cases of trisomy 21, the risk score for trisomy 21 was ≥ 99%, and the risk score for trisomy 18 was ≤ 0.01%. In all 50 cases of trisomy 18, the risk score for trisomy 21 was ≤ 0.01%, and the risk score for trisomy 18 was ≥ 99% in 47 cases, 98.8% in 1 case, 88.5% in 1 case, and 0.11% in 1 case. In 3 of the 300 euploid pregnancies (1%), no risk score was provided, because there was failed amplification and sequencing. In the remaining 297 cases, the risk score for trisomy 21 was ≤ 0.01%, and the risk score for trisomy 18 was ≤ 0.01% in 295 cases, 0.04% in 1 case, and 0.23% in 1 case. Therefore, the sensitivity for detecting trisomy 21 was 100% (50/50 cases); the sensitivity for trisomy 18 was 98% (49/50 cases), and the specificity was 100% (297/297 cases). CONCLUSION In this study, chromosome-selective sequencing of cell-free DNA separated all cases of trisomy 21 and 98% of trisomy 18 from euploid pregnancies.

First-trimester screening for neural tube defects using alpha-fetoprotein.

Objective: To assess the potential value of maternal serum alpha-fetoprotein (AFP) at 11–13 weeks’ gestation in early screening for fetal neural tube defects (NTDs). Methods: Maternal serum AFP at 11–13 weeks’ gestation was measured in 32 cases of fetal NTDs, including 18 cases of acrania and 14 cases of spina bifida, and 1,500 unaffected controls. The measured serum AFP was converted into multiple of the expected median (MoM) after adjustment for gestational age and maternal characteristics and Mann-Whitney test was used to determine the significance of difference in the mean MoM of serum AFP in the NTD group to that in the controls. Results: The mean AFP MoM in the NTD group (1.76, 95% CI 1.39–2.23) was significantly higher than in the controls (p < 0.0001). The mean AFP MoM was not significantly different between the cases of acrania and cases of spina bifida (1.78 vs. 1.75; p = 0.722). The detection rates of NTD in screening by serum AFP were 50.0% (95% CI 31.9–68.1) and 37.5% (95% CI 21.1–56.3) at fixed false-positive rates of 10 and 5%, respectively. Conclusion: Measurement ofmaternal serum AFP at 11–13 weeks’ gestation may be useful in screening for fetal NTDs.

Placental growth factor: a predictive marker for preeclampsia?

Background: An imbalance between angiogenic and antiangiogenic factors plays a fundamental role in the pathogenesis of preeclampsia. Serum levels of placental growth factor (PLGF), a factor promoting angiogenesis, in patients with preeclampsia are significantly lower than in nonpreeclamptic pregnancies. This study was designed to answer the question whether the measurement of PLGF at the beginning of the second trimester might be a predictive factor for the appearance of preeclampsia. Methods: Serum samples of 61 women were collected between 15 and 18 weeks of pregnancy. PLGF levels were measured using a human PLGF ELISA and correlated with the outcomes of pregnancy. Results: 7 women (11.47%) developed preeclampsia during pregnancy. Their PLGF levels between 15 and 18 weeks of pregnancy were significantly lower (p < 0.001) compared to the nonpreeclamptic pregnancies. Using a PLGF level of 41.84 pg/ml as a cutoff, this test has a sensitivity of 0.87 and a specificity of 0.83. Conclusion: Women who will develop preeclampsia in the course of pregnancy already have a significantly lower expression of PLGF between 15 and 18 weeks of pregnancy compared to those who will not. This test offers new possibilities in the prediction of preeclampsia.

First-trimester screening for trisomy 21 with adjustment for biochemical results of previous pregnancies.

Objective: To investigate the effect of associations in serum free β-hCG and PAPP-A between successive pregnancies on the performance of screening for trisomy 21 at 11–13 weeks’ gestation. Methods: In 8,499 women with two consecutive pregnancies, including 49 women with fetal trisomy 21 in the second pregnancy, the correlation in serum free β-hCG multiples of the median (MoM) and PAPP-A MoM between pregnancies was determined, and the effects of correcting for the correlation on the performance of screening was estimated. Results: There were significant associations between pregnancies in free β-hCG MoM (r = 0.4435) and PAPP-A MoM (r = 0.4796). In screening by maternal age and biochemistry at a risk cutoff of 1 in 100, in the second pregnancies the false-positive rate was 35.5% for those with screen-positive results in the first pregnancy, and this was reduced to 17.1% after adjustment for the results of the first pregnancy. Similarly, in women with screen-negative results in the first pregnancy, adjustment for the results improved the detection rate in the second pregnancy from 66.7 to 81.2%. Conclusions: In screening for trisomy 21, adjustment for the biochemical findings in a previous pregnancy has major effects on individual patient-specific risks, increases the detection rate and reduces the false-positive rate.

Impact of maternal serum levels of Visfatin, AFP, PAPP-A, sFlt-1 and PlGF at 11–13 weeks gestation on small for gestational age births

Abstract Objective: Investigating potential value of maternal serum Visfatin, sFlt-1, PlGF, AFP, PAPP-A levels at first trimester for prediction of small for gestational age (SGA) at birth. Methods: Measurements were performed in 20 SGA and 65 control cases. Logistic regression analysis adjusted for age and weeks of pregnancy at data collection was performed to estimate odds ratios (OR), 95% confidence intervals (95% CI) and p values separately for each potential predictor. A multiple regression model was used to assess the impact of all the promising predictors adjusted for each other. Receiver operating characteristic (ROC) analysis was used to indicate the ability to discriminate between SGA cases and controls. Results: There was an association of serum PlGF levels (OR 0.53 per interquartile range [IQR] increase in PlGF; 95% CI 0.24–1.16), sFlt-1/PlGF ratio (OR 1.42 per IQR increase in sFlt-1/PlGF; 95% CI 1.03–1.96), serum Visfatin levels (OR 0.31 per IQR increase in Visfatin; 95% CI 0.10–0.95) and smoking (OR 4.24; 95% CI 1.10–16.37) with SGA at birth. Conclusions: Associations between SGA and lower PlGF, Visfatin levels as well as increased sFlt-1/PlGF ratio and smoking status were detected which may contribute to predict SGA.

The Use of Plasma Exchange in a Very Early-onset and Life Threatening, Hemolysis, Elevated Liver Enzymes, and Low Platelet (HELLP) Syndrome: A Case Report

Background: HELLP syndrome is a life threatening pregnancy and early postpartum complication. Very early presentation (before the 21st pregnancy week) is rare and represents an extremely difficult situation for patients and physicians. Supportive therapy (magnesium sulfate, antihypertensive drugs and corticosteroids) may be useful to prolong pregnancy; till now the removing of placenta is the only effective therapeutic option. Plasmapheresis may represent a new and efficacious therapeutic option. Case description: The article reports on a case of very-early onset HELLP Syndrome at the 18th (17+5) week of gestation. It was a challenging clinical and therapeutic case. Since the fetus did not show any signs of growth retardation or pathological Doppler findings, indicating a good fetal prognosis, we used plasmapheresis as an ultima ratio to prolong pregnancy. With plasmapheresis, the pregnancy was prolonged for 20 days. Unfortunately the deterioration of the clinical situation required delivery in the 21st (20+4) gestational week. Conclusion: Plasmapheresis allows prolongation of pregnancy with early onset, life threatening HELLPSyndrome.

Maternal serum anti-Müllerian hormone at 11–13 weeks’ gestation in the prediction of preeclampsia

Abstract Objective: To investigate the potential value of maternal serum anti-Müllerian hormone (AMH) at 11–13 weeks’ gestation in the prediction of preeclampsia (PE). Methods: The serum concentration of AMH was measured at 11–13 weeks’ gestation in cases of PE (n = 50) and normotensive controls (n = 150). Backward stepwise multiple regression analysis was used to determine which of the factors amongst the maternal characteristics and gestation were significant predictors of the serum AMH in the control group and from the regression model the value in each case and control was expressed as a multiple of the expected median (MoM). Results: In normotensive pregnancies, the maternal serum concentration of AMH is higher in Afro-Caribbean than in Caucasian women and in smokers than in non-smokers. In the PE group, the median serum concentration of AMH was significantly higher than in the controls (2.140 ng/L, IQR 1.968–2.273 versus 2.062 ng/L, IQR 1.938–2.181; p = 0.025), but the median MoM value of AMH was not significantly different between the PE group and the controls (1.040, IQR 0.941–1.081 versus 0.995, IQR 0.939–1.065, p = 0.147). Conclusions: Maternal serum AMH is not an effective early predictor for PE.

Follistatin during pregnancy and its potential role as an ovarian suppressing agent

OBJECTIVE Ovarian quiescence is a common condition during pregnancy. In vitro, follistatin, an antagonist of follicle-stimulating hormone, blocks follicular development at early stages, and its serum levels increase during pregnancy. A possible surrogate biomarker of ovarian arrest during pregnancy is a decrease in anti-mullerian hormone (AMH) levels followed by an increase in these levels on the second day after labor. The purpose of this study was to determine whether follistatin could act as an ovarian-suppressing agent during pregnancy. Follistatin levels and AMH levels were determined at various stages of pregnancy and postpartum. STUDY DESIGN The follistatin and AMH levels of 69 patients were retrospectively determined with the AMH Gen II ELISA and with the Human Follistatin Quantikine ELISA Kit. For 49 patients, samples were available from various trimesters for cross-sectional analysis; for the other 20, samples were available longitudinally from day one before labor and then daily on days 1 through 4 after labor. Statistical significance was determined with linear regression, the Friedman rank sum test and the Wilcoxon-Nemenyi-McDonald-Thompson post hoc test. RESULTS The behavior of follistatin levels was exactly opposite that of AMH levels: Follistatin levels increased significantly during pregnancy and on the first day after parturition but declined afterwards, whereas AMH levels decreased significantly during pregnancy and increased after labor. CONCLUSION Follistatin can induce ovarian arrest during pregnancy.

Serum concentrations of soluble B7-H4 in early pregnancy are elevated in women with preterm premature rupture of fetal membranes

To determine the association between maternal soluble B7‐H4 (sB7‐H4) and the preterm premature rupture of the amniotic membranes (pPROM), the blood serum concentration levels of sB7‐H4 were studied.

Change of anti-Mullerian-hormone levels during follicular phase in PCOS patients.

Abstract Anti-Mullerian-hormone (AMH) does not seem to fluctuate significantly during the menstrual cycle in healthy women. However, little is known about cycle fluctuations of AMH levels in patients with polycystic ovarian syndrome (PCOS). The purpose of this study was to examine AMH fluctuations during the follicular phase in PCOS patients receiving antiestrogens or recombinant follicle-stimulating hormone (FSH). About 40 PCOS patients diagnosed according to Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group 2003 and 19 controls were prospectively enrolled. PCOS patients received either antiestrogens or recombinant FSH for monoovulation induction and controls received antiestrogens. AMH levels were determined (1) between the 2nd and the 5th day of follicular phase and (2) when a single large dominant follicle ≥18 mm had appeared. Our study shows that AMH levels do not change during follicular development in controls as well as in PCOS patients with AMH levels < 5 ng/ml, irrespective of antiestrogen or FSH therapy. However, in PCOS patients with AMH levels ≥5 ng/ml, AMH declines significantly during follicular development (p < 0.01). We conclude that AMH levels should be determined in the early follicular phase in PCOS patients without the influence of antiestrogens or exogenous FSH, because these interventions may lower AMH values in patients with high levels. Chinese abstract 抗苗勒管激素（AMH）在健康妇女月经周期中似乎并没有明显波动。然而多囊卵巢综合征（PCOS）患者月经期AMH水平的变化却鲜为人知。本研究的目的是检测PCOS患者卵泡期接受抗雌激素或重组卵泡刺激素（FSH）治疗后AMH水平的波动。其中40名患者诊断为PCOS（根据2003年欧洲人类生殖与胚胎学会和美国生殖医学会发起的PCOS共识研讨会），19人纳入对照组。PCOS患者采用抗雌激素或重组FSH诱发单卵泡发育，对照组接受抗雌激素治疗。(1)月经第2天至第5天和（2）出现单个优势卵泡（卵泡直径≥18mm）时分别监测AMH水平。我们的研究表明无论是否接受抗雌激素或FSH治疗，对照组和AMH＜5ng/ml的PCOS组AMH水平在卵泡发育过程中并没有波动。而AMH＞5ng/ml的PCOS组，AMH在卵泡发育过程中则显著下降（P＜0.01）。我们得出结论PCOS患者AMH水平应在没有接受抗雌激素或外源FSH治疗的早卵泡期测定，因为对于高AMH水平的PCOS患者这些干预治疗可能会降低AMH水平。