Associations Between Phenotypes of Preeclampsia and Thrombophilia

Home , Placental infarction

European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 199–205

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology

jou rnal homepage: www.elsevier.com/locate/ejogrb

Associations between phenotypes of preeclampsia and thrombophilia

a, a a b

Durk Berks *, Johannes J. Duvekot , Hillal Basalan , Moniek P.M. De MAAT ,

a a

Eric A.P. Steegers , Willy Visser

Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands

Department of Hematology, Erasmus MC, University Medical Center Rotterdam, The Netherlands

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: Preeclampsia complicates 2–8% of all pregnancies. Studies on the association of preeclampsia

Received 29 July 2015

with thrombophilia are conﬂicting. Clinical heterogeneity of the disease may be one of the explanations.

Received in revised form 4 September 2015

The present study addresses the question whether different phenotypes of preeclampsia are

Accepted 17 September 2015

associated with thrombophilia factors.

Study design We planned a retrospective cohort study. From 1985 until 2010 women with

Keywords:

preeclampsia were offered postpartum screening for the following thrombophilia factors: anti-

Fetal growth restriction

phospholipid antibodies, APC-resistance, protein C deﬁciency and protein S deﬁciency, hyperhomo-

HELLP syndrome

cysteineamia, factor V Leiden and Prothrombin gene mutation. Hospital records were used to obtain

Pre-eclampsia

information on phenotypes of the preeclampsia and placental histology.

Retrospective study

Thrombophilia Results: We identiﬁed 844 women with singleton pregnancies who were screened for thrombophilia

factors. HELLP complicated 49% of pregnancies; Fetal growth restriction complicated 61% of pregnancies.

Early delivery (<34th week) occurred in 71% of pregnancies. Any thrombophilia factor was present in

29% of the women. Severe preeclampsia was associated with protein S deﬁciency (p = 0.01). Fetal growth

restriction was associated with anti-phospholipid antibodies (p < 0.01). Early onset preeclampsia was

associated with anti-phospholipid antibodies (p = 0.01). Extensive placental infarction (>10%)

was associated with anti-phospholipid antibodies (p < 0.01). Low placental weight (<5th percentile)

was associated with hyperhomocysteineamia (p = 0.03). No other associations were observed.

Conclusions: Early onset preeclampsia, especially if complicated by fetal growth restriction, are

associated with anti-phospholipid antibodies. Other phenotypes of preeclampsia, especially HELLP

syndrome, were not associated with thrombophilia. We advise only to test for anti-phospholipid

antibodies after early onset preeclampsia, especially if complicated by fetal growth restriction. We

suggest enough evidence is presented to justify no further studies are needed.

Introduction seems to be associated with preeclampsia in cohort studies.

However, these results cannot be reproduced in larger prospective

Preeclampsia complicates 2–8% of all pregnancies [1]. The cause studies [1].

of preeclampsia has not yet been elucidated and is most probably An explanation of these conﬂicting results might be that

heterogenic [1]. One possible cause is a maternal pro-thrombo- preeclampsia is a heterogenic disease with different phenotypes.

genic state, leading to mal-adaptation of the spiral arteries in early Not only can preeclampsia be classiﬁed as mild or severe, it may

pregnancy and placental thrombosis and infarction in mid- and also be complicated by hemolysis, elevated liver enzymes or low

late pregnancy [1]. A pro-thrombogenic state can be caused by platelets (HELLP-syndrome) and/or intrauterine growth restriction

inherited or acquired thrombophilia [2–4]. Maternal thrombophilia (IUGR) and/or early onset preeclampsia. Histological examination

of placentas of pregnancies complicated by preeclampsia may

show extensive infarction, but also no abnormal ﬁndings at all

[5]. Some authors suggest that early preeclampsia has another

* Corresponding author at: Department of Obstetrics and Gynecology, Division of

pathophysiological basis than late preeclampsia [6]. It might be

Obstetric and Prenatal Medicine, Erasmus MC, Dr. Molewaterplein 50, 3015 GE

that these different phenotypes of preeclampsia are differently

Rotterdam, The Netherlands. Tel.: +31 10 7036686; fax: +31 10 7036815.

E-mail address: [email protected] (D. Berks). associated with thrombophilia. If this is true, future research

http://dx.doi.org/10.1016/j.ejogrb.2015.09.021

200 D. Berks et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 199–205

should be focused on the pathophysiology, prediction and Patients with an abnormal test result, except for factor V Leiden,

ultimately prevention of preeclampsia in combination with these Prothrombin gene mutation, and serum homocysteine concentra-

thrombophilia factors. tions were retested at least six weeks after the initial test. Only if

This retrospective cohort study addresses the question which the same abnormality was conﬁrmed a patient was considered

phenotypes of preeclampsia are associated with thrombophilia. positive for this coagulation abnormality. If a patient with an initial

abnormal test result was not retested, the presence or absence of

Material and methods this coagulation abnormality was reported as missing.

The percentage of placental infarction was estimated by

From 1985 until 2010 all patients with a singleton pregnancy combining macroscopy and microscopy of the placenta. Placental

who were admitted for mild or severe preeclampsia to the weight was measured without umbilical cord and membranes. The

department of obstetrics of the Erasmus Medical Centre, University percentile was calculated according to a previous study [7].

Medical Centre Rotterdam, were offered to be postpartum The thrombophilia factors were tested for associations. If more

screened for thrombophilia factors. Preeclampsia was diagnosed than one thrombophilia measurements were missing, the category

according to the deﬁnition of the International Society for the ‘one or more thrombophilia’ was also marked as missing. The

Study of Hypertension (ISSHP). Severe preeclampsia was diag- phenotypes of preeclampsia tested for associations were: HELLP

nosed if one or more of the following criteria were present: a syndrome, IUGR, early (<34 weeks) or late onset (34 weeks),

blood pressure of 160 mmHg systolic or higher or 110 mmHg minimal (<10%) versus extensive (10%) placental infarction and

diastolic or higher; proteinuria of 5 gram or more in a 24-h urine normal (>5th centile) versus low (5th centile) placental weight.

specimen or dipstick urinalysis of 3+ or greater in two random Furthermore we did a factor analysis with a ﬁxed 2-axis model.

urine samples collected at least 4 h apart; cerebral or visual For this we deﬁned 4 different subgroups with the 2 most

disturbances; elevated liver enzymes; thrombocytopenia; fetal important phenotypes of preeclampsia: IUGR and HELLP. The 4

growth restriction. HELLP was deﬁned as a combination of subgroups were deﬁned as IUGRÀ/HELLPÀ, IUGR+/HELLPÀ,

platelet count <100 Â 10 /L, serum aspartate aminotransferase IUGRÀ/HELLP+, IUGR+/HELLP+. For the above mentioned

(ASAT) 30 U/L and serum alanine aminotransferase (ALAT) 11 thrombophilia factors we used the continuous data for the

30 U/L (2 SD above the mean in our hospital). Intrauterine analysis. If more than one sample was available, we used the result

growth restriction (IUGR) was deﬁned as a birth weight below that was least abnormal.

the 10th centile. Associations of thrombophilia factors with the different

At least six weeks postpartum, patients were tested for: anti- phenotypes of preeclampsia and the factor analysis were done

cardiolipin antibodies, lupus anticoagulans, APC-ratio, levels of with the statistical software package IBM SPSS Statistics Version 20

protein C and S, homocysteine and heterozygosity for factor V (IBM Corporation, 2011) using X -tests with continuity correction.

Leiden and Prothrombin gene mutation. None of the patients were Missing values were excluded for the analysis. A two-sided p-value

using vitamin supplements during the period of testing. of less than 0.05 was considered statistical signiﬁcant.

The reference values for the coagulation assays were ascer-

tained in a population of at least 40 normal male volunteers. Anti- Results

cardiolipin antibodies were determined by enzyme-linked immu-

noassay (ELISA) according to the directives of Harris (normal A total of 844 women were tested for thrombophilia. The

values IgG and IgM <31 units GPL and <12 units MPL, respective- general characteristics of these patients are summarized in Table 1.

ly). The presence of lupus anticoagulant was determined with the Placental histology was available for 545 women.

diluted Prothrombin time (Recombiplastin, Instrumentation Lab- Table 2 shows the preeclampsia phenotypes and the preva-

oratories, Italy, normal ratio < 1.20) and the activated partial lence of the thrombophilia. Overall 29% of the women had one or

thromboplastin time assay (Platelin, Organon Teknika, USA, more abnormal thrombophilia results. Severe preeclampsia was

normal value < 40 s). Effect of factor deﬁciency was eliminated signiﬁcantly associated with a higher presence of one or more

by mixing 1:1 patient and normal pool plasma. Protein S (normal thrombophilia result (p = 0.01) and with more prevalent protein-S

range 0.70–1.40 U/ml) was determined as protein S activity by a deﬁciency (p = 0.01) compared to mild preeclampsia. IUGR was

clotting assay (Diagnostica Stago, France) and as free protein S by signiﬁcantly associated with a higher presence of one or more

an ELISA (Biopool, USA). Protein S deﬁciency is deﬁned as an thrombophilia factors (p < 0.01) and more prevalent anti-

outcome of <0.70 (IU/ml) for two assays at least 6 weeks apart phospholipid antibodies (p < 0.01) compared to normal grown

without use of oral contraceptives. Protein C (normal range 0.70–

1.40 U/ml) deﬁciency was determined by measuring protein C

Table 1

activity (IL Testkit ProclotTM Proclot, Instrumentation Laboratory,

General characteristics (N = 844); values are presented as % of the study population

Italy) and protein C antigen by a house-made ELISA with the use of

(n) or as median (range).

rabbit antihuman anti-protein C (Dako Cytomation, Denmark).

Maternal age at conception (years) 29 (17–43)

Protein C deﬁciency is deﬁned as an outcome of <0.70 (IU/ml) for

Nulliparous 74% (627)

two assays at least 6 weeks apart. Gestational age at delivery (weeks) 31 (27–40)

Serum homocysteine concentrations were measured both after Gestational age at onset of 29 (15–40)

preeclampsia (weeks)

(an overnight) fasting and 6 h after an oral loading dose of

Severe preeclampsia 91% (768)

L-methionine (0.1 g/kg body weight). During the test the patients

HELLP syndrome 49% (413)

were given a standardized methionine-poor breakfast and lunch. Intra uterine growth restriction 61% (512)

EDTA-blood samples were kept on ice and plasma was separated Eclampsia 3% (28)

Placental abruption 4% (30)

within 1 h for determination of homocysteine. Plasma total

Birth weight (grams) 1090 (275–3720)

homocysteine was determined using HPLC with ﬂuorescence

Birth weight percentile 3.1 (0–100)

detection. The patients were considered to have hyperhomocys-

Fetal death 14% (116)

teineamia if the fasting homocysteine concentration exceeded Information on placental histology 65% (545)

15 mmol/L and/or the post-load value exceeded 45 mmol/L. Placental weight (grams) 235 (45–700)

Placental weight percentile 6.5 (0–100)

Factor V Leiden and Prothrombin gene mutation were deter-

Placental infarction (%) 5 (0–90)

mined by polymerase chain reaction.

D. Berks et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 199–205 201

fetuses. Early onset preeclampsia (gestational age <34 weeks at

delivery) was signiﬁcantly associated with a higher presence of

one or more thrombophilia factors (p < 0.01) and more prevalent

p5 anti-phospholipid antibodies (p = 0.01) compared to late pre-

eclampsia (gestational age 34weeks at delivery). Increased

placental infarction (10% of total volume) was signiﬁcantly

associated with more prevalent anti-phospholipid antibodies

(p < 0.01) compared to normal placental infarction (<10% of total p5 /237 (3.8%) 8/193 (4.1%)

volume). A low placental weight (5th percentile) was signiﬁ-

%) 12/237 (5.1%) 13/194 (6.7%) 2%) 16/221 (7.2%) 10/185 (5.4%) cantly associated with more prevalent hyperhomocysteineamia

8%) 14/185 (7.6%) 9/159 (5.7%)

(p = 0.03) compared to normal placental weight (>5th percentile).

HELLP was not associated with any thrombophilia. The following

10%

1/118 (0.8%) 1/230 (0.4%) 1/188 (0.5%) thrombophilia factors were not associated with any phenotype of

preeclampsia: Protein-C deﬁciency, APC-resistance, factor V

Leiden mutation and Prothrombin gene mutation.

Table 3 shows adjusted odds-ratios for thrombophilia factors if

51 (34.2%) 48/116 (41.4%) 82/217 (37.8%) 61/180 (33.9%)

only HELLP or only IUGR is present. After adjusting for gestational 10%

age at onset of preeclampsia, correlations with IUGR disappear for

protein-S deﬁciency.

.3%) 55/336 (16.4%) 19/113 (16.8%) 42/209 (20.1%) 24/176 (13.6%)

The factor analysis with ﬁxed 2-axis model performed poorly,

only explaining 34% of the variance in the results of thrombophilia

34 weeks factors. < 101/323 (31.3%) 66/200 (33.0%) 20/78 (25.6%) 28/111 (25.2%) 46/117 (39.3%)

Discussion

Thrombophilia was more present if the preeclampsia was 34 weeks

severe, combined with IUGR, a delivery before the 34th week of

gestation, placental infarction was more than 10% or placental

weight was lower than the 5th centile. To our knowledge this

is the largest cohort-study so far, testing for the association

between different phenotypes of preeclampsia and thrombo- 0.05).

< philia.

Previous studies show wide ranges in the prevalence of

thrombophilia factors as shown in Table 4. This is probably caused

by differences in known confounders [8] like laboratory methods,

chosen cut-off points to deﬁne abnormal results, deﬁnition of the

presence of thrombophilia factors (one or two positive tests),

timing of the testing and heterogeneity of the cases race,

gestational age at delivery and preeclampsia severity.

If preeclampsia was severe, we found a higher prevalence of

protein-S deﬁciency. Associations disappeared when testing for

the other phenotypes of preeclampsia. Two previous studies also

found a signiﬁcant association between severe preeclampsia

compared to normal controls [9,10].

If preeclampsia was accompanied with IUGR, we found a higher

prevalence of anti-phospholipid antibodies. Yasuda et al. [11]

found similar results in 22 women with IUGR without preeclamp-

sia, while another study did not ﬁnd this association in 25 women

[12]. Other studies did not perform a comparative analysis [13] or

were unable to do so because of a 94% incidence of IUGR in their

cohort [14].

In early preeclampsia we found a higher prevalence of anti-

phospholipid antibodies. Another study did not show a difference

Mild Severe Absent Present Absent Present in anti-phospholipid antibodies in women with preeclampsia that

delivered before and after the 28th gestational week [15].

In case of increased placental infarction >10% we found a higher

prevalence of anti-phospholipid antibodies. No previous study

tested this association.

239/740 (32.3%) 12/68 (17.6%) 227/672 (33.8%) 108/369 (29.3%) 131/371 (35.3%) 74/295 (25.1%) 163/443 (36.8%) 49/208 (23.6%) 190/532 (35.7%) 120/3 38/807 (4.7%)25/806 1/75 (3.1%) (1.3%) 2/75 37/732 (2.7%) (5.1%) 23/731 20/410 (3.1%) (4.9%) 9/409 18/397 (2.2%) (4.5%) 16/397 11/322 (3.4%) (4.0%) 27/482 9/321 (5.6%) (2.8%) 6/237 16/482 (2.5%) (3.3%) 32/570 4/237 (5.6%) (1.7%) 21/380 21/569 (5.5%) (3.7%) 10/122 13/380 (8.2 (3.4%) 6/121 (5.0%) 9 45/640 (7.0%) 6/56 (10.7%) 39/584 (6.7%) 20/321 (6.2%) 25/319 (7.8%) 15/246 (6.1%) 28/392 (7.1%) 12/182 (6.6%) 33/458 (7.2%) 22/301 (7.3%) 6/103 (5.

59/759 (7.8%) 3/72 (4.2%) 56/687 (8.2%) 27/391 (6.9%) 32/368 (8.7%) 15/294 (5.1%) 44/463 (9.5%) 8/220 (3.6%) 51/539 (9.5%) 22/353 (6.2%)In 16/121case (13. of a low placental weight 5th percentile we found a

higher prevalence of hyperhomocysteineamia. Only one previous

study found an association between elevated homocysteine levels

and placental vasculopathy [16]. One study showed an increased

placental weight when folic acid supplementation was started

preconceptionally [17]. Since folic acid lowers homocysteine

factor (heterozygous) gene mutation (heterozygous) (FVL excluded) antibodies

1 thrombophilia levels, these and our results suggest that elevated homocysteine

Factor Overall Preeclampsia severity HELLP syndrome IUGR Gestational age Placental infarction Placental weight percentile Hyperhomocysteineamia 125/424Factor V Leiden (29.5.8%) 6/30Prothrombin (20.0%) 119/394 (30.2%) 51/193 (26.4%) 74/231 (32.0%) 37/141 (26.2%) 88/283 (31.1%) 24/101 (23.8%) APC Resistance Anti-phospholipid Protein-C deﬁciencyProtein-S deﬁciency 6/778 99/720 (0.8%) (13.8%) 0/72 2/66 (0.0%) (3.0%) 6/706 97/654 (14.8%) (0.8%) 43/354 2/395 (12.1%) 56/366 (0.5%) (15.3%) 4/383 32/292 (11.0%) (1.0%) 67/425 3/311 (15.8%) (1.0%) 20/204 (9.8%) 3/464 79/516 (0.6%) (15 2/229 (0.9%) 4/549 (0.7%) 3/368 (0.8%)

Table 2 Prevalence of thrombophilia factors (ﬁgures presented as % (total tested in subgroup), greyed numbers represent levels could impair placental growth capability.

202 D. Berks et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 199–205

Table 3

Odds-ratios for phenotypes of preeclampsia, grey cells ﬂag p < 0.05.

Factor Model 1 Model 2 Model 3

IUGR without HELLP (cases = 241, controls = 190)

One or more thrombophilia factor 2.02 (1.26–3.22) 1.87 (1.16–3.01) 1.79 (1.05–3.05)

Anti-phospholipid antibodies 1.6 (0.7–3.67) 1.43 (0.61–3.32) 0.99 (0.39–2.53)

Protein-C deﬁciency 0.85 (0.05–13.61) 0.98 (0.06–16.26) 2.93 (0.15–58)

Protein-S deﬁciency 2.21 (1.11–4.39) 2.01 (1–4.04) 1.87 (0.86–4.03)

APC Resistance (FVL excluded) 1.9 (0.71–5.07) 2.02 (0.74–5.53) 2.37 (0.8–7.01)

Hyperhomocysteineamia 1.38 (0.71–2.68) 1.46 (0.74–2.86) 1.62 (0.75–3.49)

Factor V Leiden (heterozygous) 1.58 (0.62–4.03) 1.45 (0.56–3.77) 1.16 (0.41–3.31)

Prothrombin gene mutation (heterozygous) 0.65 (0.17–2.47) 0.53 (0.13–2.13) 0.42 (0.09–1.92)

HELLP without IUGR (cases = 138, controls = 190)

One or more thrombophilia factor 1.54 (0.91–2.61) 1.41 (0.82–2.41) 1.39 (0.8–2.41)

Anti-phospholipid antibodies 0.92 (0.32–2.66) 0.98 (0.33–2.88) 0.82 (0.27–2.44)

Protein-C deﬁciency 2.81 (0.25–31.35) 2.43 (0.22–27.35) 2.22 (0.18–27.15)

Protein-S deﬁciency 2.06 (0.97–4.34) 1.81 (0.85–3.87) 1.97 (0.89–4.33)

APC Resistance (FVL excluded) 2.11 (0.73–6.12) 1.89 (0.64–5.55) 1.81 (0.61–5.41)

Hyperhomocysteineamia 1.5 (0.7–3.18) 1.58 (0.73–3.4) 1.68 (0.77–3.67)

Factor V Leiden (heterozygous) 0.77 (0.22–2.7) 0.68 (0.19–2.41) 0.51 (0.14–1.85)

Prothrombin gene mutation (heterozygous) 1.09 (0.29–4.14) 1.01 (0.26–3.89) 0.98 (0.25–3.87)

HELLP and IUGR (cases = 271, controls = 190)

One or more thrombophilia factor 2.21 (1.41–3.47) 2.05 (1.29–3.26) 2 (1.15–3.45)

Anti-phospholipid antibodies 2.16 (0.98–4.73) 2.1 (0.95–4.67) 1.15 (0.46–2.88)

Protein-C deﬁciency 1.45 (0.13–16.13) 1.4 (0.12–15.99) 3.11 (0.11–91.97)

Protein-S deﬁciency 2.17 (1.12–4.23) 1.67 (0.84–3.34) 1.92 (0.85–4.35)

APC Resistance (FVL excluded) 1.59 (0.6–4.24) 1.76 (0.64–4.83) 2.81 (0.89–8.89)

Hyperhomocysteineamia 1.63 (0.88–3.03) 1.79 (0.95–3.36) 1.9 (0.91–3.97)

Factor V Leiden (heterozygous) 1.47 (0.58–3.71) 1.41 (0.55–3.65) 0.84 (0.28–2.5)

Prothrombin gene mutation (heterozygous) 1.76 (0.61–5.07) 1.63 (0.55–4.79) 1.51 (0.43–5.25)

Controls: no IUGR and no HELLP.

Model 1: crude estimates.

Model 2: adjusted for maternal age at conception and nulliparous.

Model 3: model 2 + adjusted for gestational age at onset of preeclampsia.

We found no association between HELLP and any kind of This study has several limitations. Firstly, bias in patient

thrombophilia, unlike other studies [5,10,18]. The factor analysis inclusion before 2006 could not be excluded. Until 2006 mainly

did not show any association in the continuous results also. severe cases of preeclampsia were being screened for thrombo-

Our study found no association between any of the philia. Since 2006 screening for thrombophilia is offered to all

preeclampsia phenotypes and factor V Leiden. Previous cohort women with preeclampsia. Secondly, placental infarction was not

and case-control studies showed conﬂicting results on the scored using a standardized protocol, lowering the power of the

association between the occurrence of preeclampsia and factor ﬁndings with regard to placental infarction. Thirdly, the tests of

V Leiden [10,12,18–28]. However, reported prevalence range association we performed were numerous, causing multiple-

widely from 2% to 28%. Ethnicity may explain some of this testing. Forth, abnormality of some factors of thrombophilia had a

variance, next to small study groups and bias due to study design. low prevalence in this population (protein-C), leading to a probable

In larger studies [15,29] as well as in prospective cohort studies power-problem. On the other hand, the low prevalence indicates a

(systematically review by Rodger et al. [30]) prevalence ranged low clinical value, sustaining our conclusion.

from 3 to 7%, showing no association with preeclampsia and are The most important strength of this study is the high number

in line with our ﬁndings. This leaves factor V Leiden only a of cases, which enabled comparisons between preeclampsia

possible associated factor in Ashkenazi-Jews, but not in phenotypes.

Caucasians. Overall, preeclampsia is associated with anti-phospholipid

We found no associations with Prothrombin gene mutations. antibodies in case of early onset preeclampsia and in association

Previous cohort and case-control studies showed conﬂicting with placental insufﬁciency (placental infarction and IUGR), but

results [10,18–21,24,25,27,31]. However, a systematic reviews of not with HELLP syndrome. We hypothesize that this is due to the

only prospective cohort studies [30], showed no associations. fact that this thrombophilic factor does not act through systemic

We found no associations with protein-C deﬁciency and (non- coagulation pathways, but at the placental side. Ernst et al. report

factor V Leiden) APC-resistance. Although the incidence in our on the pathophysiologic mechanisms of anti-phospholipid syn-

population was very low, it conﬁrms the ﬁndings in other studies drome [36]. The primary hypothesis is that anti phospholipid

[12,18,20,26,32,33]. antibodies cause placental thrombosis, leading to placental

Whether IUGR should be a deﬁning condition of preeclampsia is infarction. The associations we found between anti phospholipid

still under debate. In its revised classiﬁcation of hypertensive antibodies and placental infarctions, impaired fetal growth and

disorders in pregnancy, the ACOG removed IUGR as deﬁning deliveries before the 34th gestational week conﬁrm this hypothe-

condition of preeclampsia [34], whilst meanwhile the ISSHP added sis, since the one phenotype is very likely to result from the other.

IUGR as deﬁning condition of preeclampsia [35]. Adjusting the One acting mechanism might be through Beta-2GP1 molecule,

analysis in Table 2, column ‘preeclampsia severity’ for the presence present on the surface of trophoblastic cell membranes. It appears

or absence of IUGR, which is more in line with the new deﬁnition of to inhibit thrombosis by reducing the conversion of Prothrombin

the ACOG, signiﬁcance was lost for ‘1 thrombophilia factor’, to thrombin on platelets and inhibiting the activation of the

whilst the other outcomes remained the same (results not shown). intrinsic coagulation cascade [36]. Beta-2GP1 antibodies block the Table 4 Overview of studies on preeclampsia and thrombophilia (C: cohort study, C-C: Case-control study, PC: prospective cohort study, SR: systematic review, SPE: severe preeclampsia, MPE: mild preeclampsia, PlacPath: placental pathology, ACA: anti-cardiolipin antibodies, LAC: lupus anti-coagulans, PCD: protein-C deﬁciency, PSD: protein-S deﬁciency, rAPC: APC-resistance, HHC: hyperhomocysteineamia, MLT: methionine loading test, FVL: factor V Leiden, PGM: Prothrombine gene mutation).

Study Study-type Comparisons n (PE) All AFS PCD PSD rAPC HHC FVL PGM Country (Ethnicity) Special remarks

ACA LAC Æ,++ Æ,++ Current C ÆSPE, ÆIUGR, ÆHELLP, 890 32.9% 9.0% 1.9% 0.7% 13.5% 7.1% 28.9% 5.0% 2.9% Netherlands 91% severe PE, ÆPlacPath, Æ34w 2 Â positive = positive 1995, Dekker et al. [9] C ÆSPE Netherlands 100% severe, FVL not

yet known D.

2001, Many et al. [38] C ÆSPE, ÆIUGR, 101 28.4% 0.0% 1.2% 24.7% 16% 17.7% Israel Placental parameters Berks ÆPlacPath

2002, Sikkema et al. [5] C-C ÆPlacPath 25 48.0% Netherlands SPE and/or IUGR et

<34w, al.

1 Â positive = positive European 2005, Mello et al. [10] C-C ÆSPE, ÆMPE 47 68% 4% 7% 13% 9% 57% 21% Italy, 100% Caucasian 100% mild PE 2006, Van Rijn et al. [39] CPEÆ HELLP, 402 16.7% 3.2% 3.2% 4.0% Netherlands 100% early onset PE, 1 Â positive = positive

PE Æ IUGR, Æ28w Only total Journal thrombophilia

factors compared of

2008, Muetze et al. [27] C ÆHELLP 120 24% 0.8% 2.5% 1.7% 3% 17% 11% Germany 100% HELLP Obstetrics 2009, Facchinetti et al. [40] C ÆSPE 68 16.9% 4.2% Italy, 100% Caucasian 60% severe PE, 2 Â positive = positive Only total

thrombophilia &

factors compared Gynecology 2009, Kahn et al. [19] C-C ÆPE 60 46.7% 35% 20% 11.7% 28.3% 20% Montreal, Canada ?% severe PE 2010, Sep et al. [18] CPEÆ HELLP 113 5.4% 14.3% 2.7% Netherlands 100% HELLP 2010, Sep et al. [18] CPEÆ HELLP 75 8% 3% 0% 4% 2.0% 3% Netherlands 100% PE without HELLP

and Robertson 2006 [41] SR ÆPE, ÆIUGR 481 8.9% 9.1% 2.9% 5.0% 32.1% 11.3% 7.2%% 3.5% 481 –

1995, Yasuda et al. [11] PC PEÆ S, ÆIUGR 22 31.2% Japan 36% severe PE Reproductive 1998, Nagy et al. [28] C-C ÆSPE 69 18.8% Hungary, 100% Cauc 100% severe PE 1999, Kupferminc et al. [25] C-C ÆSPE, ÆIUGR 34 26.5% 5.9% Israel, 44% Ashkenazi 100% severe PE 1999, Mello et al. [26] C-C ÆPE 46 2.2% 2.2% 2.2% 4.3% 26.1% 26.1%% Italy, 100% Caucasian 1999, O’Shaughnessy et al. [29] C ÆPE 283 5.3% UK

1999, Van Pampus et al. [15] C-C ÆSPE, Æ28w 345 11.3% 12.1% 6.0% Netherlands 100% severe, Biology 1 Â positive = positive

2000a, Kupferminc et al. [31] C-C ÆSPE, ÆMPE, ÆIUGR 80 8.8% Israel, 96% Ashkenazi Severe PE (n = 55); 194 PGM 9.1%

Mild PE (n = 25): (2015) PGM = 8.0% ÆSPE 63 66.7% 3.2% 0.0% 7.9% 23.8% 7.9% Israel, 25% Ashkenazi 100% Severe PE 2000b, Kupferminc et al. [20] C-C 2001, Alﬁrevic et al. [12] C-C ÆSPE, ÆIUGR 63 14.3% 9.5% 15.9% 28.6% 1.6% UK, 88% Caucasian 100% Severe PE 199–205 2001, Dreyfus et al. [32] C-C ÆPE 180 3.9% 0.6% France 35% Severe PE 2002, Agorastos et al. [21] C-C ÆPE, ÆIUGR 16 18.8% 0.0% Greece 2002, Benedetto et al. [22] C-C ÆPE, PE Æ HELLP, 111 7.2% 7.2% Italy PE + HELLP (n = 32): PE Æ IUGR FVL 15.6%, PGM 6.4% PE + IUGR (n = 31): FVL 9.6%, PGM 3.2% 2002, Currie et al. [23] C-C ÆSPE 48 8.3% Australia 100% Severe PE 2002, D’Elia et al. [24] C-C ÆPE 58 5.2% 1.7% Italy

Rodger 2010 [30] SR ÆPE, ÆIUGR 1060 5.1% 4.0% 2000, Murphy et al. [42] PC ÆPE, ÆIUGR 12 0.0% Ireland 2004, Salomon et al. [43] PC ÆPE, ÆIUGR 29 34.5% Israel (only LAC, FVL, PGM) 203

204 D. Berks et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 199–205

Beta-2GP1 molecule, so it can no longer inhibit thrombosis.

Another acting mechanism might be the disruption of annexin V,

that normally binds to the phospholipid molecules on the surface

of the trophoblastic membrane, preventing thrombosis by forming

a protective protein coat.

In 2012 the FRUIT-study [37], a randomized controlled trial

studying the effect of low-molecular weight heparin on recurrence

risk of preeclampsia in women with thrombophilia, suggests that if

inheritable thrombophilia like protein-S deﬁciency are present,

administration of aspirin and low molecular weight heparin during

a next pregnancy may decrease the recurrence risk. Studies

measuring the effect of low-molecular weight heparin on the

recurrence risk of preeclampsia in thrombophilic women with

acquired thrombophilia like anti-phospholipid syndrome are

10% African Amer, 19% Hisp 34% African Amer, 33% Hisp

currently being conducted.

In conclusion, phenotyping of preeclampsia can help to 4.7% US, 31% Cauc,

,++

determine if screening for thrombophilia is warranted. We advise

to screen for anti-phospholipid antibodies after early onset

preeclampsia, especially if complicated by IUGR. We do not

0.0% 0.0% Greece 3.7% US,7.0% 69% Cauc, 2.1% Australia 4.7% Scotland

recommend routine screening for thrombophilia and screening ,++

after other phenotypes of preeclampsia. We suggest that enough

evidence is presented to conclude that associations between

preeclampsia and thrombophilia are not clinically important and

further studies should not be conducted.

Authors’ contribution

D. Berks designed the study, collected, analyzed and inter-

preted the data and wrote the manuscript. J.J. Duvekot

interpreted the data and critically reviewed the manuscript. H.

Basalan designed the study, partially collected the data and

partially wrote the manuscript. M.P.M. de Maat designed the

study an critically reviewed the manuscript. E.A.P. Steegers

critically reviewed the manuscript. W. Visser designed the study,

collected and interpreted the data and critically reviewed the

manuscript. All authors reviewed and approved the ﬁnal version

of the manuscript.

ACA LAC

Conﬂict of interest

The authors report no conﬂict of interest. 8 3466 5.9% Sweden (PE) All AFS PCD PSD rAPC HHC FVL PGM Country (Ethnicity) Special remarks 134 243 129

n Acknowledgements

We are very thankful to M. Ahmadi and S. Petronia in carefully

33w

checking and re-checking the data. Æ

IUGR IUGR, IUGR IUGR IUGR IUGR References Æ Æ Æ Æ Æ Æ

PE, PE, PE, PE, PE, PE,

[1] Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet Æ Æ Æ Æ Æ Æ

2010;376(August (9741)):631–44.

[2] Kupferminc MJ. Thrombophilia and pregnancy. Reprod Biol Endocrinol

2003;1:111.

[3] Thornton P, Douglas J. Coagulation in pregnancy. Best Pract Res Clin Obstet

Gynaecol 2010;24(June (3)):339–52.

PC PC PC PC PC PC

[4] de Maat MP, de Groot CJ. Thrombophilia and pre-eclampsia. Semin Thromb

Hemost 2011;37(March (2)):106–10.

[44] [5] Sikkema JM, Franx A, Bruinse HW, van der Wijk NG, de Valk HW, Nikkels PG.

Placental pathology in early onset pre-eclampsia and intra-uterine growth

restriction in women with and without thrombophilia. Placenta 2002;23(April [45] (4)):337–42. [33]

[46]

[6] Roberts JM, Hubel CA. The two stage model of preeclampsia: variations on the [48]

[47]

theme. Placenta 2009;30(March (Suppl. A)):S32–7.

)

[7] Naeye RL. Do placental weights have clinical signiﬁcance? Hum Pathol

1987;18(April (4)):387–91.

[8] Kist WJ, Janssen NG, Kalk JJ, Hague WM, Dekker GA, de Vries JI. Thrombophilias

and adverse pregnancy outcome – a confounded problem! Thromb Haemost Continued

2008;99(January (1)):77–85.

[9] Dekker GA, de Vries JI, Doelitzsch PM, et al. Underlying disorders associated

2008, Clark et al. 2006, Lindqvist et al. 2010, Silver et al. 2005, Dizon-Thownson et al. 2008, Karakantza et al. 2008, Dudding et al.

with severe early-onset preeclampsia. Am J Obstet Gynecol 1995;173(October Study Study-type Comparisons

Table 4 ( (4)):1042–8.

D. Berks et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 199–205 205

[10] Mello G, Parretti E, Marozio L, et al. Thrombophilia is signiﬁcantly associated [30] Rodger MA, Betancourt MT, Clark P, et al. The association of factor V leiden and

with severe preeclampsia: results of a large-scale, case-controlled study. prothrombin gene mutation and placenta-mediated pregnancy complica-

Hypertension 2005;46(December (6)):1270–4. tions: a systematic review and meta-analysis of prospective cohort studies.

[11] Yasuda M, Takakuwa K, Tokunaga A, Tanaka K. Prospective studies of the PLoS Med 2010;7(June (6)):e1000292.

association between anticardiolipin antibody and outcome of pregnancy. [31] Kupferminc MJ, Peri H, Zwang E, Yaron Y, Wolman I, Eldor A. High prevalence

Obstet Gynecol 1995;86(October (4 Pt 1)):555–9. of the prothrombin gene mutation in women with intrauterine growth

[12] Alﬁrevic Z, Mousa HA, Martlew V, Briscoe L, Perez-Casal M, Toh CH. Postnatal retardation, abruptio placentae and second trimester loss. Acta Obstet Gynecol

screening for thrombophilia in women with severe pregnancy complications. Scand 2000;79(November (11)):963–7.

Obstet Gynecol 2001;97(May (5 Pt 1)):753–9. [32] Dreyfus M, Hedelin G, Kutnahorsky R, et al. Antiphospholipid antibodies

[13] de Vries JI, Dekker GA, Huijgens PC, Jakobs C, Blomberg BME, van Geijn HP. and preeclampsia: a case-control study. Obstet Gynecol 2001;97(January

Hyperhomocysteinaemia and protein S deﬁciency in complicated pregnancies. (1)):29–34.

Br J Obstet Gynaecol 1997;104:1248–54. [33] Lindqvist PG, Svensson P, Dahlback B. Activated protein C resistance – in the

[14] Ganzevoort W, Rep A, De Vries JI, Bonsel GJ, Wolf H. Relationship between absence of factor V Leiden – and pregnancy. J Thromb Haemost 2006;4(Feb-

thrombophilic disorders and type of severe early-onset hypertensive disorder ruary (2)):361–6.

of pregnancy. Hypertens Pregnancy 2007;26(4):433–45. [34] Hypertension in pregnancy: executive summary of the ACOG guideline. Obstet

[15] van Pampus MG, Dekker GA, Wolf H, et al. High prevalence of hemostatic Gynecol 2013;122(5):1122–31.

abnormalities in women with a history of severe preeclampsia. Am J Obstet [35] Tranquilli AL, Dekker G, Magee L, et al. The classiﬁcation, diagnosis and

Gynecol 1999;180(May (5)):1146–50. management of the hypertensive disorders of pregnancy: a revised statement

[16] van der Molen EF, Verbruggen B, Novakova I, Eskes TK, Monnens LA, Blom HJ. from the ISSHP. Pregnancy Hypertens 2014;4(April (2)):97–104.

Hyperhomocysteinemia and other thrombotic risk factors in women with [36] Ernest JM, Marshburn PB, Kutteh WH. Obstetric antiphospholipid syndrome:

placental vasculopathy. BJOG 2000;107(June (6)):785–91. an update on pathophysiology and management. Semin Reprod Med

[17] Timmermans S, Jaddoe VW, Hofman A, Steegers-Theunissen RP, Steegers EA. 2011;29(November (6)):522–39.

Periconception folic acid supplementation, fetal growth and the risks of low [37] de Vries JI, van Pampus MG, Hague WM, Bezemer PD, Joosten JH. Low-

birth weight and preterm birth: the Generation R Study. Br J Nutr molecular-weight heparin added to aspirin in the prevention of recurrent

2009;102(September (5)):777–85. early-onset pre-eclampsia in women with inheritable thrombophilia: the

[18] Sep S, Verbeek J, Koek G, Smits L, Spaanderman M, Peeters L. Clinical differ- FRUIT-RCT. J Thromb Haemost 2012;10(January (1)):64–72.

ences between early-onset HELLP syndrome and early-onset preeclampsia [38] Many A, Schreiber L, Rosner S, Lessing JB, Eldor A, Kupferminc MJ. Pathologic

during pregnancy and at least 6 months postpartum. Am J Obstet Gynecol features of the placenta in women with severe pregnancy complications and

2010;202(March (3)):271.e1–.e5. thrombophilia. Obstet Gynecol 2001;98(December (6)):1041–4.

[19] Kahn SR, Platt R, McNamara H, et al. Inherited thrombophilia and preeclampsia [39] van Rijn BB, Hoeks LB, Bots ML, Franx A, Bruinse HW. Outcomes of subsequent

within a multicenter cohort: the Montreal Preeclampsia Study. Am J Obstet pregnancy after ﬁrst pregnancy with early-onset preeclampsia. Am J Obstet

Gynecol 2009;200(February (2)):151.e1–.e9. discussion e1–5. Gynecol 2006;195(September (3)):723–8.

[20] Kupferminc MJ, Fait G, Many A, Gordon D, Eldor A, Lessing JB. Severe pre- [40] Facchinetti F, Marozio L, Frusca T, et al. Maternal thrombophilia and the risk of

eclampsia and high frequency of genetic thrombophilic mutations. Obstet recurrence of preeclampsia. Am J Obstet Gynecol 2009;200(January (1)):

Gynecol 2000;96(July (1)):45–9. 46.e1–e5.

[21] Agorastos T, Karavida A, Lambropoulos A, et al. Factor V Leiden and prothrom- [41] Robertson L, Wu O, Langhorne P, et al. Thrombophilia in pregnancy: a

bin G20210A mutations in pregnancies with adverse outcome. J Matern Fetal systematic review. Br J Haematol 2006;132(January (2)):171–96.

Neonatal Med 2002;12(October (4)):267–73. [42] Murphy RP, Donoghue C, Nallen RJ, et al. Prospective evaluation of the risk

[22] Benedetto C, Marozio L, Salton L, Maula V, Chieppa G, Massobrio M. Factor V conferred by factor V Leiden and thermolabile methylenetetrahydrofolate

Leiden and factor II G20210A in preeclampsia and HELLP syndrome. Acta reductase polymorphisms in pregnancy. Arterioscler Thromb Vasc Biol

Obstet Gynecol Scand 2002;81(December (12)):1095–100. 2000;20(January (1)):266–70.

[23] Currie L, Peek M, McNiven M, Prosser I, Mansour J, Ridgway J. Is there an [43] Salomon O, Seligsohn U, Steinberg DM, et al. The common prothrombotic

increased maternal-infant prevalence of Factor V Leiden in association with factors in nulliparous women do not compromise blood ﬂow in the feto-

severe pre-eclampsia? BJOG 2002;109(February (2)):191–6. maternal circulation and are not associated with preeclampsia or intrauter-

[24] D’Elia AV, Driul L, Giacomello R, et al. Frequency of factor V, prothrombin and ine growth restriction. Am J Obstet Gynecol 2004;191(December (6)):

methylenetetrahydrofolate reductase gene variants in preeclampsia. Gynecol 2002–9.

Obstet Investig 2002;53(2):84–7. [44] Dizon-Townson DS, Nelson LM, Easton K, Ward K. The factor V Leiden muta-

[25] Kupferminc MJ, Eldor A, Steinman N, et al. Increased frequency of genetic tion may predispose women to severe preeclampsia. Am J Obstet Gynecol

thrombophilia in women with complications of pregnancy. N Engl J Med 1996;175(October (4 Pt 1)):902–5.

1999;340(January (1)):9–13. [45] Karakantza M, Androutsopoulos G, Mougiou A, Sakellaropoulos G, Kour-

[26] Mello G, Parretti E, Martini E, et al. Usefulness of screening for congenital or ounis G, Decavalas G. Inheritance and perinatal consequences of inherited

acquired hemostatic abnormalities in women with previous complicated thrombophilia in Greece. Int J Gynaecol Obstet 2008;100(February

pregnancies. Haemostasis 1999;29(4):197–203. (2)):124–9.

[27] Muetze S, Leeners B, Ortlepp JR, et al. Maternal factor V Leiden mutation is [46] Dudding T, Heron J, Thakkinstian A, et al. Factor V Leiden is associated with

associated with HELLP syndrome in Caucasian women. Acta Obstet Gynecol pre-eclampsia but not with fetal growth restriction: a genetic association

Scand 2008;87(6):635–42. study and meta-analysis. J Thromb Haemost 2008;6(November (11)):1869–

[28] Nagy B, Toth T, Rigo Jr J, Karadi I, Romics L, Papp Z. Detection of factor V Leiden 75.

mutation in severe pre-eclamptic Hungarian women. Clin Genet 1998;53(June [47] Clark P, Walker ID, Govan L, Wu O, Greer IA. The GOAL study: a prospective

(6)):478–81. examination of the impact of factor V Leiden and ABO(H) blood groups on

[29] O’Shaughnessy KM, Fu B, Ferraro F, Lewis I, Downing S, Morris NH. Factor V haemorrhagic and thrombotic pregnancy outcomes. Br J Haematol 2008;

Leiden and thermolabile methylenetetrahydrofolate reductase gene variants 140(January (2)):236–40.

in an East Anglian preeclampsia cohort. Hypertension 1999;33(June (6)): [48] Silver RM, Zhao Y, Spong CY, et al. Prothrombin gene G20210A mutation and

1338–41. obstetric complications. Obstet Gynecol 2010;115(January (1)):14–20.