26
Studies have shown that EOPE and LOPE are distinct entities with different pathologies (Von Dadelszen et al., 2003, Walker, 2000). These entities differ in pathological features and in maternal and fetal outcomes (Raymond and Peterson, 2011). Masuyama et al., (2010) have stated that angiogenic factor levels varies between EOPE and LOPE. EOPE is associated more with altered cardiovascular function resulting from placental disorder while LOPE is related more to maternal factors (Valensise et al., 2008). The finding from this current study shows a significant increase in the level of circulating cffDNA and cftDNA in EOPE and LOPE groups compared to the level in the control group, but the level did not vary between EOPE and LOPE. This finding is in keeping with the study carried out by Papantoniou et al., who noted the level of cffDNA in EOPE was not different from the level in LOPE, though the number EOPE to LOPE in their study was only 2 out of a total 24 preeclamptic women (Papantoniou et al., 2013). Though the results obtained in this study did not show any difference in the level of circulating cffDNA and cftDNA between EOPE compared to LOPE, Papantoniou et al., (2013) have shown that the circulation levels of these markers can be used to identify women who are likely to develop preeclampsia at an early stage, as the circulating concentration of fetal and total DNA in this women are elevated in the early stages of pregnancy. These authors have also stated that the increase in the level of circulating cfDNA in the early stages of pregnancy correlates to the altered placentation which is an initiating factor of PE (Papantoniou et al., 2013). This finding supports the hypothesis that cfDNA elevation in PE is due to impaired trophoblastic invasion of maternal spiral arteries leading to placental ischemia and damage, with the consequent release of apoptotic syncytiotrophoblast fragments that contain fetal DNA.
27
therefore necessary that the use of cfDNA alone or in combination with other tests be fully standardised for the diagnosis and monitoring of preeclampsia and other complications of pregnancy.
28
4 REFERENCES
Abalos, E., Cuesta, C., Grosso, A. L., Chou, D. & Say, L. 2013. Global and regional estimates of preeclampsia and eclampsia: a systematic review. European Journal of Obstetrics & Gynecology and Reproductive Biology, 170, 1-7.
Abdelhalim, R. M., Ramadan, D. I., Zeyada, R., Nasr, A. S. & Mandour, I. A. 2016. Circulating Maternal Total Cell-Free DNA, Cell-Free Fetal DNA and Soluble Endoglin Levels in Preeclampsia:
Predictors of Adverse Fetal Outcome? A Cohort Study. Molecular diagnosis & therapy, 20, 135- 149.
Alberry, M., Maddocks, M., Jones, M., Abdel Hadi, M., Abdel-Fattah, S., Avent, N. & Soothill, P. 2007.
Free fetal DNA in maternal plasma in anembryonic pregnancies: confirmation that the origin is the trophoblast. Prenatal diagnosis, 27, 415-418.
Alberry, M. S., Maddocks, D. G., Hadi, M. A., Metawi, H., Hunt, L. P., Abdel-Fattah, S. A., Avent, N. D.
& Soothill, P. W. 2009. Quantification of cell free fetal DNA in maternal plasma in normal pregnancies and in pregnancies with placental dysfunction. American Journal of Obstetrics and Gynecology, 200, 98.e1-98.e6.
Barra, G. B., Santa Rita, T. H., De Almeida Vasques, J., Chianca, C. F., Nery, L. F. A. & Costa, S. S. S.
2015. EDTA-mediated inhibition of DNases protects circulating cell-free DNA from ex vivo degradation in blood samples. Clinical biochemistry.48, 976-981
Barra, S., Do Carmo Cachulo, M., Providência, R. & Leitão-Marques, A. 2012. Hypertension in pregnancy:
The current state of the art. Revista Portuguesa de Cardiologia (English Edition), 31, 425-432.
BianchI, D. 2004. Circulating fetal DNA: its origin and diagnostic potential—a review. Placenta, 25, S93- S101.
Borzychowski, A. M., Sargent, I. L. & Redman, C. W. G. 2006. Inflammation and pre-eclampsia. Seminars in Fetal and Neonatal Medicine, 11, 309-316.
Chan, K. A., Ding, C., Gerovassili, A., Yeung, S. W., Chiu, R. W., Leung, T. N., Lau, T. K., Chim, S. S., Chung, G. T. & Nicolaides, K. H. 2006. Hypermethylated RASSF1A in maternal plasma: a
29
universal fetal DNA marker that improves the reliability of noninvasive prenatal diagnosis. Clinical chemistry, 52, 2211-2218.
Chim, S. S., Tong, Y. K., Chiu, R. W., Lau, T. K., Leung, T. N., Chan, L. Y., Oudejans, C. B., Ding, C. &
Lo, Y. D. 2005. Detection of the placental epigenetic signature of the maspin gene in maternal plasma. Proceedings of the National Academy of Sciences of the United States of America, 102, 14753-14758.
Craici, I. M., Wagner, S. J., Bailey, K. R., Fitz-Gibbon, P. D., Wood-Wentz, C. M., Turner, S. T., Hayman, S. R., White, W. M., Brost, B. C. & Rose, C. H. 2013. Podocyturia Predates Proteinuria and Clinical Features of Preeclampsia Longitudinal Prospective Study. Hypertension, 61, 1289-1296.
Cruz, M. O., Gao, W. & Hibbard, J. U. 2012. What is the optimal time for delivery in women with gestational hypertension? American Journal of Obstetrics and Gynecology, 207, 214.e1-214.e6.
Cuckle, H., Benn, P. & Pergament, E. 2015. Cell-free DNA screening for fetal aneuploidy as a clinical service. Clinical Biochemistry. 48, 932-941.
Daniels, G., Finning, K., Martin, P. & Massey, E. 2009. Noninvasive prenatal diagnosis of fetal blood group phenotypes: current practice and future prospects. Prenatal diagnosis, 29, 101-107.
Devaney, s. a., Palomaki, G. E., Scott, J. A. & Bianchi, D. W. 2011. Noninvasive fetal sex determination using cell-free fetal DNA: a systematic review and meta-analysis. Jama, 306, 627-636.
Eastabrook, G., Brown, M. & Sargent, I. 2011. The origins and end-organ consequence of pre-eclampsia.
Best Practice & Research Clinical Obstetrics & Gynaecology, 25, 435-447.
Fong, F. M., Sahemey, M. K., Hamedi, G., Eyitayo, R., Yates, D., Kuan, V., Thangaratinam, S. & Walton, R. T. 2014. Maternal genotype and severe preeclampsia: a HuGE review. American Journal of Epidemiology, 180, 335-345.
Ghulmiyyah, L. & Sibai, B. 2012. Maternal Mortality From Preeclampsia/Eclampsia. Seminars in Perinatology, 36, 56-59.
Goulopoulou, S. & Davidge, S. T. 2015. Molecular mechanisms of maternal vascular dysfunction in preeclampsia. Trends in molecular medicine, 21, 88-97.
30
Granger, J. P., Alexander, B. T., Bennett, W. A. & Khalil, R. A. 2001. Pathophysiology of pregnancy- induced hypertension. American Journal of Hypertension, 14, 178S-185S.
Hahn, S., Giaglis, S., Buser, A., Hoesli, I., Lapaire, O. & Hasler, P. 2014. Cell-free nucleic acids in (maternal) blood: any relevance to (reproductive) immunologists? Journal of reproductive immunology, 104, 26-31.
Hahn, S., Rusterholz, C., Hösli, I. & Lapaire, O. 2011. Cell-free nucleic acids as potential markers for preeclampsia. Placenta, 32, S17-S20.
Hill, M., Barrett, A. N., White, H. & Chitty, L. S. 2012. Uses of cell free fetal DNA in maternal circulation.
Best Practice & Research Clinical Obstetrics & Gynaecology, 26, 639-654.
Huppertz, B. 2004. Apoptosis in the trophoblast—role of apoptosis in placental morphogenesis. Journal of the Society for Gynecologic Investigation, 11, 353-362.
Hutcheon, J. A., Lisonkova, S. & Joseph, K. 2011. Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy. Best practice & research Clinical obstetrics & gynaecology, 25, 391-403.
Jakobsen, T. R., Clausen, F. B., Rode, l., Dziegiel, M. H. & Tabor, A. 2013. Identifying mild and severe preeclampsia in asymptomatic pregnant women by levels of cell‐free fetal DNA. Transfusion, 53, 1956-1964.
Kim, H. J., Kim, S. Y., Lim, J. H., Kwak, D. W., Park, S. Y. & Ryu, H. M. 2015. Quantification and application of potential epigenetic markers in maternal plasma of pregnancies with hypertensive disorders. International journal of molecular sciences, 16, 29875-29888.
Lazar, L., Rigó, J., Nagy, B., Balogh, K., Makó, V., Cervenak, L., Mézes, M., Prohászka, Z. & Molvarec, A. 2009. Relationship of circulating cell-free DNA levels to cell-free fetal DNA levels, clinical characteristics and laboratory parameters in preeclampsia. BMC medical genetics, 10, 120.
Li, X., Tan, H., Huang, X., Zhou, S., Hu, S., Wang, X., Xu, X., Liu, Q. & Wen, S. W. 2016. Similarities and differences between the risk factors for gestational hypertension and preeclampsia: A population based cohort study in south China. Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health, 6, 66-71.
31
Lin, S., Leonard, D., Co, M. A. M., Mukhopadhyay, D., Giri, B., Perger, L., Beeram, M. R., Kuehl, T. J. &
Uddin, M. N. 2015. Pre-eclampsia has an adverse impact on maternal and fetal health.
Translational Research, 165, 449-463.
Lisonkova, S. & Joseph, K. 2013. Incidence of preeclampsia: risk factors and outcomes associated with early-versus late-onset disease. American journal of obstetrics and gynecology, 209, 544. e1-544.
e12.
Lo, Y. M. D., Corbetta, N., Chamberlain, P. F., Rai, V., Sargent, I. L., Redman, C. W. G. & WAINSCOAT, J. S. 1997. Presence of fetal DNA in maternal plasma and serum. The Lancet, 350, 485-487.
Lui, Y. Y., Chik, K.-W., Chiu, R. W., Ho, C.-Y., Lam, C. W. & Lo, Y. D. 2002. Predominant hematopoietic origin of cell-free DNA in plasma and serum after sex-mismatched bone marrow transplantation.
Clinical chemistry, 48, 421-427.
Mackay, A. P., Berg, C. J. & Atrash, H. K. 2001. Pregnancy‐related mortality from preeclampsia and eclampsia. Obstetrics & Gynecology, 97, 533-538.
Magee, L. A., Pels, A., Helewa, M., Rey, E. & Von Dadelszen, P. 2014. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health, 4, 105-145.
Magee, L. A., Pels, A., Helewa, M., Rey, E. & Von Dadelszen, P. 2015. The hypertensive disorders of pregnancy (29.3). Best Practice & Research Clinical Obstetrics & Gynaecology, 29, 643-657.
Mandel, P. M., P 1948. Les acides nucleiques du plasma sanguin chez l’Homme. C R Acad Sci Paris, 142, 241-243.
Manokhina, I., Singh, T. K., Peñaherrera, M. S. & Robinson, W. P. 2014. Quantification of cell-free DNA in normal and complicated pregnancies: overcoming biological and technical issues. PloS one, 9, e101500.
Martin, A., Krishna, I., Martina, B. & Samuel, A. 2014. Can the quantity of cell‐free fetal DNA predict preeclampsia: a systematic review. Prenatal diagnosis, 34, 685-691.
Masuyama, H., Segawa, T., Sumida, Y., Masumoto, A., Inoue, S., Akahori, Y. & Hiramatsu, Y. 2010.
Different profiles of circulating angiogenic factors and adipocytokines between early‐and late‐
onset pre‐eclampsia. BJOG: An International Journal of Obstetrics & Gynaecology, 117, 314-320.
32
Moezzi, L., Keshavarz, Z., Ranjbaran, R., Aboualizadeh, F., Behzad-Behbahani, A., Abdullahi, M., Ramezani, A., Samsami, A. & Sharifzadeh, S. 2016. Fetal RHD Genotyping Using Real-Time Polymerase Chain Reaction Analysis of Cell-Free Fetal DNA in Pregnancy of RhD Negative Women in South of Iran. International journal of fertility & sterility, 10, 62.
Mol, B. W., Roberts, C. T., Thangaratinam, S., Magee, L. A., De Groot, C. J. & Hofmeyr, G. J. 2016. Pre- eclampsia. The Lancet, 387, 999-1011.
Moodley, J. 2011. Maternal deaths associated with hypertension in South Africa: lessons to learn from the Saving Mothers report, 2005–2007. Cardiovascular journal of Africa, 22, 31.
Naljayan, M. V. & Karumanchi, S. A. 2013. New developments in the pathogenesis of preeclampsia.
Advances in chronic kidney disease, 20, 265-270.
Noori, M., Donald, A. E., Angelakopoulou, A., Hingorani, A. D. & Williams, D. J. 2010. Prospective study of placental angiogenic factors and maternal vascular function before and after preeclampsia and gestational hypertension. Circulation, 122, 478-487.
Osungbade, K. O. & Ige, O. K. 2011. Public health perspectives of preeclampsia in developing countries:
implication for health system strengthening. Journal of pregnancy, 2011.
Papantoniou, N., Bagiokos, V., Agiannitopoulos, K., Kolialexi, A., Destouni, A., Tounta, G., Kanavakis, E., Antsaklis, A. & Mavrou, A. 2013. RASSF1A in maternal plasma as a molecular marker of preeclampsia. Prenatal diagnosis, 33, 682-687.
Powe, C. E., Levine, R. J. & Karumanchi, S. A. 2011. Preeclampsia, a disease of the maternal endothelium the role of antiangiogenic factors and implications for later cardiovascular disease. Circulation, 123, 2856-2869.
Rahman, M., Abe, S., Kanda, M., Narita, S., Rahman, M., Bilano, V., Ota, E., Gilmour, S. & Shibuya, K.
2015. Maternal body mass index and risk of birth and maternal health outcomes in low‐and middle‐
income countries: a systematic review and meta‐analysis. Obesity Reviews, 16, 758-770.
Ramsay, J. E., Ferrell, W. R., Crawford, L., Wallace, A. M., Greer, I. A. & Sattar, N. 2002. Maternal obesity is associated with dysregulation of metabolic, vascular, and inflammatory pathways. The Journal of Clinical Endocrinology & Metabolism, 87, 4231-4237.
33
Raymond, D. & Peterson, E. 2011. A critical review of early-onset and late-onset preeclampsia. Obstetrical
& gynecological survey, 66, 497-506.
Reddy, A., Zhong, X., Rusterholz, C., Hahn, S., Holzgreve, W., Redman, C. & Sargent, I. 2008. The effect of labour and placental separation on the shedding of syncytiotrophoblast microparticles, cell-free DNA and mRNA in normal pregnancy and pre-eclampsia. Placenta, 29, 942-949.
Redman, C. W. G. 2011. Preeclampsia: A multi-stress disorder. La Revue de Médecine Interne, 32, Supplement 1, S41-S44.
Redman, C. W. G. & Sargent, I. L. 2001. The pathogenesis of pre-eclampsia. Gynécologie Obstétrique &
Fertilité, 29, 518-522.
Romero-Arauz, J., Ortiz-Díaz, C., Leaños-Miranda, A. & Martínez-Rodríguez, O. 2014. [Progression of gestational hypertension to preeclampsia]. Ginecologia y obstetricia de Mexico, 82, 229-235.
Salvianti, F., Inversetti, A., Smid, M., Valsecchi, L., Candiani, M., Pazzagli, M., Cremonesi, L., Ferrari, M., Pinzani, P. & Galbiati, S. 2015. Prospective evaluation of RASSF1A cell-free DNA as a biomarker of pre-eclampsia. Placenta, 36, 996-1001.
Saudan, P., Brown, M. A., Buddle, M. L. & Jones, M. 1998. Does gestational hypertension become pre‐
eclampsia? BJOG: An International Journal of Obstetrics & Gynaecology, 105, 1177-1184.
Saving Mothers 2011-2013. A short report of the National Committee on Confidential Enquiries into Maternal Deaths. Pattinson R ed. Nat Dept of Halth. Pretoria. 2015.
Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller, A.-B., Daniels, J., Gülmezoglu, A. M., Temmerman, M. & Alkema, L. 2014. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health, 2, e323-e333.
Sekizawa, A., Jimbo, M., Saito, H., Iwasaki, M., Matsuoka, R., Okai, T. & Farina, A. 2003. Cell-free fetal DNA in the plasma of pregnant women with severe fetal growth restriction. American Journal of Obstetrics and Gynecology, 188, 480-484.
Sekizawa, A., Kondo, T., Iwasaki, M., Watanabe, A., Jimbo, M., Saito, H. & Okai, T. 2001. Accuracy of fetal gender determination by analysis of DNA in maternal plasma. Clinical chemistry, 47, 1856- 1858.
34
Shah, D. M. 2007. Preeclampsia: new insights. Current opinion in nephrology and hypertension, 16, 213- 220.
Sibai, B. M. 2003. Diagnosis and management of gestational hypertension and preeclampsia. Obstetrics &
Gynecology, 102, 181-192.
Sibai, B. M. 2011. Management of Late Preterm and Early-Term Pregnancies Complicated by Mild Gestational Hypertension/Pre-Eclampsia. Seminars in Perinatology, 35, 292-296.
Sifakis, S., Koukou, Z. & Spandidos, D. A. 2015. Cell-free fetal DNA and pregnancy-related complications (Review). Molecular medicine reports, 11, 2367-2372.
Sifakis, S., Zaravinos, A., Maiz, N., Spandidos, D. A. & Nicolaides, K. H. 2009. First-trimester maternal plasma cell-free fetal DNA and preeclampsia. American journal of obstetrics and gynecology, 201, 472. e1-472. e7.
Souza, J. P., Gülmezoglu, A. M., Vogel, J., Carroli, G., Lumbiganon, P., Qureshi, Z., Costa, M. J., Fawole, B., Mugerwa, Y. & Nafiou, I. 2013. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross- sectional study. The Lancet, 381, 1747-1755.
Steegers, E. A. P., Von dadelszen, P., Duvekot, J. J. & Pijnenborg, R. 2010. Pre-eclampsia. The Lancet, 376, 631-644.
Swank, M., Caughey, A., Farinelli, C., Main, E., Melsop, K., Gilbert, W. & Chung, J. 2014. The impact of change in pregnancy body mass index on the development of gestational hypertensive disorders.
Journal of Perinatology, 34.
Taglauer, E., Wilkins-Haug, L. & Bianchi, D. 2014. Review: cell-free fetal DNA in the maternal circulation as an indication of placental health and disease. Placenta, 35, S64-S68.
Tannetta, D. & Sargent, I. 2013. Placental disease and the maternal syndrome of preeclampsia: missing links? Current hypertension reports, 15, 590-599.
Thangaratinam, S., Koopmans, C. M., Iyengar, S., Zamora, J., Ismail, K. M., Mol, B. W. & Khan, K. S.
2011. Accuracy of liver function tests for predicting adverse maternal and fetal outcomes in women with preeclampsia: a systematic review. Acta obstetricia et gynecologica Scandinavica, 90, 574- 585.
35
Tranquilli, A. L., Dekker, G., Magee, L., Roberts, J., Sibai, B. M., Steyn, W., Zeeman, G. G. & Brown, M.
A. 2014. The classification, diagnosis and management of the hypertensive disorders of pregnancy:
A revised statement from the ISSHP. Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health, 4, 97-104.
Valensise, H., Vasapollo, B., Gagliardi, G. & Novelli, G. P. 2008. Early and late preeclampsia two different maternal hemodynamic states in the latent phase of the disease. Hypertension, 52, 873-880.
Villar, J., Carroli, G., Wojdyla, D., Abalos, E., Giordano, D., Ba'Aqeel, H., Farnot, U., Bergsjø, P., Bakketeig, L., Lumbiganon, P., Campodónico, L., Al-Mazrou, Y., Lindheimer, M. & Kramer, M.
2006. Preeclampsia, gestational hypertension and intrauterine growth restriction, related or independent conditions? American Journal of Obstetrics and Gynecology, 194, 921-931.
Von Dadelszen, P., Magee, L. A. & Roberts, J. M. 2003. Subclassification of preeclampsia. Hypertension in pregnancy, 22, 143-148.
Walker, J. J. 2000. Pre-eclampsia. The Lancet, 356, 1260-1265.
Watanabe, K., Naruse, K., Tanaka, K., Metoki, H. & Suzuki, Y. 2013. Outline of definition and classification of “pregnancy induced hypertension (PIH)”. Hypertension Research in Pregnancy, 1, 3-4.
Watson, J. D. & Crick, F. H. The structure of DNA. Cold Spring Harbor Symposia on Quantitative Biology, 1953. Cold Spring Harbor Laboratory Press, 123-131.
White, H. E., Dent, C. L., Hall, V. J., Crolla, J. A. & Chitty, L. S. 2012. Evaluation of a novel assay for detection of the fetal marker RASSF1A: facilitating improved diagnostic reliability of noninvasive prenatal diagnosis. PloS one, 7, e45073.
Yu, H., Shen, Y., Ge, Q., He, Y., Qiao, D., Ren, M. & Zhang, J. 2013. Quantification of maternal serum cell-free fetal DNA in early-onset preeclampsia. International journal of molecular sciences, 14, 7571-7582.
Zejskova, L., Jancuskova, T., Kotlabova, K., Doucha, J. & Hromadnikova, I. 2010. Feasibility of fetal- derived hypermethylated RASSF1A sequence quantification in maternal plasma—Next step toward reliable non-invasive prenatal diagnostics. Experimental and molecular pathology, 89, 241- 247.
36 APENDIX A
Figure 1. Standard curve using known concentration of genomic DNA to determine the concentration of circulating cffDNA and cftDNA in plasma.
37 APENDIX B Research approval from the Kwazulu-Natal Department of health
38 APENDIX C
Ethical Approval from the University of Kwazulu-Natal Biomedical Research Ethics Committee (BREC)
39 APENDIX D
Prince Mshiyeni Memorial Hospital Approval Letter to Conduct Research
40 APENDIX E
DATA SHEET: characterising cell free DNA in normal pregnancy and in hypertensive disorders of pregnancy in black South African women.
Study site: ………Study number: ……….
Study groups: Normotensive, Gestational hypertension, Mild/moderate Preeclampsia, Severe Preeclampsia.
GENERAL HOSPITAL INFORMATION:
Hospital number Admission number
PATIENT DEMOGRAPHICS:
Date of Birth Rural dweller Urban dweller Life style
Clinical Data Gravidity Parity
Gestational age Maternal Height Maternal weight Systolic blood pressure Diastolic blood pressure Proteinuria
HIV Status
If HIV positive, CD4 count BABY OUTCOME:
Baby’s Birth Weight:
Baby’s gender:
Favourable /unfavourable
41 APENDIX F
INFORMED CONSENT FORM Consent to Participate in Research
Dear Ms, Miss, Mrs:
I am sister Mkhize, carrying out a study with Mr Eche who is studying for a masters degree at University of Kwazulu-Natal .We will require half a tea spoon (5ml) of blood from you. We will take the blood the same time your doctors are take their blood samples for antenatal care. The taking of blood may cause you slight discomfort.
Our study may lead to finding out whether we can diagnose people with high blood pressure in early pregnancy. This may not be of help to you at the moment, but in future it may be of help to other pregnant women. Your taking part in this study is on your own free will (voluntary) and you can refuse. If you do not want to be in the study, you will not be treated differently from other patients. Our study also does not interfere with the normal treatment you get.
The results of this study will be published but no names will be used. The reason for publishing is so that other doctors and nurses can learn about our findings and because Mr Eche will get a higher qualification.
Note that we may ask you a few questions about your previous pregnancy and this current pregnancy, the same questions asked at the time of your first visit to the clinic. All the information will be kept in a locked cupboard and burnt/ destroyed once the study is over.
Please do not hesitate to let me know if you would like more information.
Thank You
____________________ ____________________
Signature of Participant Date
____________________ _____________________
Signature of Witness Date (Ms P Mkhize)