C ONGRESSIONAL B RIEFING M OLECULAR D IAGNOSTICS : “M EETING THE C HALLENGES OF WOMEN ’ S HEALTH ” Under the auspices of The Society for Women’s Health Thursday, July 9, 2009

Garrett Childers was delivered at 33 weeks gestation.

For the next several weeks, both mother and baby fought for their lives in two different hospitals.

Miranda Childers suffered multiple organ failure and internal bleeding.

But ultimately she pulled through.

Unfortunately, baby Garrett never went home with his mom and dad.

He died one week after his birth.

Zoe Olivia Jacobson’s birth was so quick and relatively easy, her mother’s first words were, “That’s it?”

Shortly after delivering, Zoe’s mother, Susan, had an eclamptic seizure, but soon recovered and even breastfed her baby.

Hours later, Susan suffered a stroke and within 48 hours was completely brain dead.

With her baby resting against her head and her family members by her side, life support systems were discontinued.

Within three days of giving birth, Susan had died from post-partum HELLP Syndrome.

Molecular Diagnosis of PREECLAMPSIA Shiraz Sunderji, MD FACOG Professor of Obstetrics & Gynecology University of Toledo Department of Maternal Fetal Medicine The Toledo Hospital – ProMedica Health System Toledo, Ohio

A CKNOWLEDGEMENT Professor Ananth Karumanchi, MD Harvard Medical School Linda C. Rogers, PhD, DABCC, FACB Beckman Coulter, Inc Eleni Z. Tsigas Preeclampsia Foundation

P REECLAMPSIA Only occurs in humans Incidence 5 % of pregnancies. 200,000 Moms in USA 6 million World wide Leading cause of death & disability mothers and infants. 70,000 maternal deaths World wide every year Characterized by new onset of proteinuria and hypertension after 20 weeks of pregnancy Cause of Preeclampsia remains unknown.

R ISKS TO THE FETUS IUGR Utero placental insufficiency Prematurity Death

R ISKS FOR THE M OTHER Seizures Renal failure Liver failure Pulmonary edema Stroke Coagulation Death

R ISKS TO THE MOTHER Long term risk of cardiovascular disease Stroke Cerebral infarction

C OST TO THE SOCIETY Loss of productivity by the mother Family separation due to prolonged hospitalization of the mother Prematurity Long term care cost and loss of productivity of the premature baby

P REECLAMPSIA No clinically useful screening test Antihypertensive therapy lowers the blood pressure but does not improve the fetal outcome. The only “cure” is delivery of the placenta.

T HEORIES OF PREECLAMPSIA Immunologic derangement Genetic factors Increased insulin resistance Dietary calcium deficiency Oxidative stress Prostaglandin imbalance Environmental factors

D ISAPPOINTING PREVENTION TRIALS Low dose aspirin to prevent preeclampsia in high risk NEJM 1998 Trial of Calcium to prevent preeclampsia NEJM 1997 Vitamins C and E and the risks of preeclampsia NEJM 2006

P REECLAMPSIA IS CAUSED BY GENERALIZED ENDOTHELIAL DYSFUNCTION

E NDOTHELIAL DYSFUNCTION IS CAUSED BY EXCESSIVE AMOUNTS OF ANTI ENDOTHELIAL FACTORS RELEASED BY DISEASED PLACENTA

ENDOTHELIAL DYSFUNCTION LEADS TO : Hypertension - disturbed endothelial control of vascular tone Proteinuria - increased glomerular vascular permeability Coagulopathy – abnormal expression of pro & anti coagulants Liver Dysfunction – ischemia & vasoconstriction

N ORMAL P LACENTAL D EVELOPMENT “R EMODELING OF SPIRAL ARTERIOLES ” Cytotrophoblast invade the endothelium & the muscular tunica media. Invading trophoblast undergo “ Pseudo - vasculogenesis” and alter their expression of adhesion molecules from epithelial to endothelial.

P LACENTAL D EVELOPMENT Normal development involves extensive angiogenesis: -Fetal trophoblasts invade maternal spiral arteries -Spiral arteries are remodeled into low resistance vessels -Placental perfusion is enhanced Abnormal placental development & dysfunction of the maternal vascular endothelium underlie preeclampsia.

ANGIOGENESIS VEGF – vascular endothelial growth factor

B IOMARKERS OF P LACENTAL D YSFUNCTION sVEGF R1 Soluble Vascular Endothelial Growth Factor Receptor 1 Also known as soluble fms-like tyrosine kinase 1 (sFlt-1) Anti-angiogenic protein Elevated in preeclampsia

B IOMARKERS OF P LACENTAL D YSFUNCTION PlGF Placental Growth Factor Angiogenic protein, promotes angiogenesis Binds to VEGF Receptor (VEGF R1 and sVEGF R1) Free PlGF is reduced in preeclampsia

sVEGF R1PlGF sVEGF R1 Normal PregnancyPreeclampsia Healthy endothelial cell Maintains vascular tone Maintains glomerular filtration Maintains blood-brain barrier Maintains anti-coagulant state Endothelial cell injury Hypertension Proteinuria Cerebral edema Coagulation/liver function abnormalities Anti-angiogenic state: anti↑ / pro↓

Hypothesis Increased systemic sVEGF R1 (produced by placenta) antagonism of VEGF & PlGF Widespread endothelial effects: Vasoconstriction, hypertension renal (glomerular) endothelial cell damage coagulation abnormalities

From Levine et al, NEJM 350(7): , 2004

M EDIAN LEVELS OF S VEGF R1

S VEGF R1 R ECEIVER O PERATING C HARACTERISTICS A NALYSIS

M EDIAN LEVELS OF P L GF

P L GF R ECEIVER O PERATING C HARACTERISTICS A NALYSIS

C ONCLUSIONS Access® prototype assays* for sVEGF R1 and PlGF demonstrated high sensitivity and specificity for the clinical diagnosis of preterm preeclampsia. Both assays clearly separated subjects with preeclampsia from normotensive and hypertensive subjects who did not develop preeclampsia. * Assays are under development and not available for clinical use.

L ONG - TERM IMPLICATIONS FOR WOMEN WITH PREECLAMPSIA Increased incidence of salt-sensitive HTN (Sibai et al, AJOG 1991, Wilson et al, BMJ 2003) Increased risk for cardiovascular mortality (Irgens et al, BMJ 2001, Funai E et al, Epidemiology 2005, Arnadottir et al, BJOG 2005) Increased incidence of chronic renal disease reports of focal sclerosis, increased incidence of renal biopsies, ESRD- Norwegian study – Vikse et al, JASN 2006, NEJM 2008

L ONG - TERM M ETABOLIC A LTERATIONS Abnormal lipids (Sattar et al, Hypertension, 2003) Abnormal endothelial function (Agatisa et al, Am J Physiol, 2004) Increased insulin resistance (Laivuori et al, J Clin Endocrinol Metab, 1996)

L ONG TERM EFFECTS ON THE P RETERM OR G ROWTH R ESTRICTED F ETUS Fetal origins of chronic adult diseases

Why do we need a diagnostic tool? To confirm or rule-out diagnosis of preeclampsia Provide more definitive diagnosis for women who do not meet traditional criteria of preeclampsia Prevents/reduces over-diagnosis Current risk stratification Determine management/treatment delivery To differentiate condition from imitators Chronic hypertension Renal disease, SLE Thrombophilia Vascular diabetes mellitus Acute fatty liver of pregnancy Provide reassurance to patient, physician

Why do we need early diagnosis? For rule-in Frequent follow-up with MFM specialist Early measures may help Steroids for fetal maturation Specific interventions are under investigation Aid obstetrician in the decision of when to deliver (emergency delivery is often needed to save both baby and mother) For rule-out Keep baby in utero Eliminate unnecessary intervention Peace of mind for both patient and physician

Copyright (c) 2005 Preeclampsia Foundation