http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, Early Online: 1–4 ! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2014.998191

ORIGINAL ARTICLE

Tenascin C levels in patients with mild and severe preeclampsia J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/11/15 For personal use only.

_ Ugur Orak1, Ebru Celik2, Salih Burcin Kavak1, Ismail Demirel3, Remzi Atilgan1, Suleyman Aydin4, and Ekrem Sapmaz1 1

Department of Obstetrics and Gynecology, Firat Medical Center, School of Medicine, Firat University, Elazig, Turkey, 2Department of Obstetric and Gynecology, Special Medical Park Hospital, Elazig, Turkey, 3Department of Anesthesia and Reanimation, and 4Department of Biochemistry, Firat University, Elazig, Turkey Abstract

Keywords

Objective: To determine the serum tenascin-C (TN-C) levels in cases with mild and severe preeclampsia. Methods: Pregnant women were divided into three groups, namely healthy pregnants (Group 1, n ¼ 20), pregnants with mild preeclampsia (Group 2, n ¼ 20) and pregnants with severe preeclampsia (Group 3, n ¼ 20). The groups were formed so as to match each other in terms of gestational week. From each pregnant woman, pre- and post-delivery blood samples were obtained to measure serum TN-C levels. The data were evaluated using the Kruskall–Wallis variance analysis. For the obtained values of p50.05, the groups were compared in pairs. A p value of 50.017 was accepted as significant. Results: In Groups 1, 2 and 3, the prepartum TN-C levels were 5.02 ± 0.4 mg/ml, 12.8 ± 2.9 mg/ml and 33.8 ± 11.7 mg/ml, and in the postpartum TN-C levels were 4.7 ± 0.1 mg/ml, 11.7 ± 1.8 mg/ml and 50.6 ± 33.8 mg/ml, respectively. There was a significant difference between the groups in terms of the prepartum and postpartum TN-C levels (p50.017, Mann–Whitney U [MWU] test). There was also a significant difference in the prepartum TN-C levels between Groups 2 and 3 (p50.017, MWU test). Conclusions: The prepartum and postpartum TN-C levels were significantly higher in mild and severe preeclampsia than those in healthy pregnants.

Cytokine, preeclampsia, tenascin-C

Introduction The hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia and HELLP syndrome remain a leading cause of maternal and perinatal mortality and morbidity worldwide. They account for nearly 18% of all maternal deaths worldwide, with an estimated 62 000– 77 000 deaths per year [1–3]. However, the pathogenesis of preeclampsia is only partially understood, and it is related to disturbances in placentation at the beginning of pregnancy, followed by generalized inflammation and progressive endothelial damage [4]. The mechanisms held responsible for the pathophysiology of preeclampsia include insufficient trophoblastic invasion, placental ischemia, generalized vasospasm, abnormal hemostasis accompanying activation of the coagulation system, vascular endothelial dysfunction, abnormal nitric oxide and lipid metabolism, leucocyte activation and changes in cytokine levels [5,6]. Tenascin-C (TN-C), a large extracellular matrix glycoprotein, was first described in 1984. It is the founding member of

Address for correspondence: Dr. Salih Burcin Kavak, Assistant Professor, Department of Obstetrics and Gynecology, Firat Medical Center, Elazig, Turkey. E-mail: [email protected]

History Received 24 September 2014 Revised 5 December 2014 Accepted 10 December 2014 Published online 8 January 2015

the gene family (Tenascin), which includes structurally similar tenascin X, V and R [7–10]. Some studies have shown that TN-C increases in disorders causing vascular endothelial damage such as hypertension and atherosclerosis [11,12]. The pro-anti-inflammatory cytokines within the tissue framework of TN-C are regulated by transforming growth factor, fibroblast growth factor and platelet growth factor. These cytokines may increase or inhibit TN-C production [13,14]. The purpose of this study was to assess the serum TN-C levels in pregnant women with mild preeclampsia and severe preeclampsia, as well as in healthy pregnant women, and to determine the relationship between TN-C levels and these disorders.

Research design and methods This study included 60 pregnant women presenting to the Department of Gynecology and Obstetrics, Medical School, Fırat University, Elazıg, Turkey, between July 2012 and February 2013. This study was begun after having obtained the approval of the Hospital Ethics Committee. The pregnant women were divided into groups of healthy pregnants (Group 1, n ¼ 20), pregnants with mild preeclampsia

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Table 1. The obstetrical and demographic features of the test and control groups. Group 1 (n ¼ 20)

Group 2 (n ¼ 20)

Group 3 (n ¼ 20)

p value

27.6 ± 1.5 35 ± 1.7 2.4 ± 0.4 1.4 ± 0.3 28.6 ± 0.6 3220 ± 159

30.2 ± 1.2 35 ± 1.8 3 ± 0.3 1.6 ± 0.3 28.4 ± 0.6 2158 ± 184

26.5 ± 1.4 35 ± 1.7 2.5 ± 0.5 1.4 ± 0.4 28.8 ± 0.5 2126 ± 167

NS NS NS NS NS *

Age (year) Gestational week when sample was obtained (week) Gravida (number) Parity (number) BMI (kg/m2) Birth weight (gram)

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Values are expressed as mean ± SEM. *p50.017, MWU test. NS: p40.05, KW variance analysis; BMI, body mass index.

Table 2. The laboratory parameters of the groups.

AST(U/L) ALT(U/L) LDH(U/L) WBC ( 103) Htc (%) Hb (g/dl) Plt ( 103)

Group 1 (n ¼ 20)

Group 2 (n ¼ 20)

Group 3 (n ¼ 20)

p value

21.6 ± 1.2 19.5 ± 0.6 243.7 ± 12.7 10.4 ± 0.1 3.9 ± 0.2 11.3 ± 0.4 258.4 ± 19.8

31.8 ± 3.7 18.5 ± 2.2 297.5 ± 28.2 10.1 ± 0.6 36.1 ± 0.6 11.6 ± 0.2 252.4 ± 20.4

30.3 ± 2.8 19.4 ± 2.2 314.2 ± 32 10.8 ± 0.7 35.9 ± 0.8 11.5 ± 0.3 255.6 ± 13.3

NS NS NS NS NS NS NS

Values are expressed as mean ± SEM and %. AST, aspartate aminotransferase; ALT, alanine transaminase; LDH, lactate dehydrogenase; WBC, white blood cell; Hct, hematocrit; Hb, hemoglobin; Plt, platelet; NS: p40.05; KW variance analysis.

(Group 2, n ¼ 20) and pregnants with severe preeclampsia (Group 3, n ¼ 20). The groups were formed so as to match each other in terms of gestational week. Exclusion criteria were multiple gestation, gestational diabetes mellitus, chronic hypertension, infectious diseases recognized in pregnancy, premature rupture of membrane, active labor, polyhydramnios and signs of other concurrent medical complication. The women in control group had no sign of gestational complications and fetal distress and gave birth to healthy neonates of appropriate size for gestational age. Gestational age was calculated by menstrual dating. Ultrasound was performed to confirm pregnancy and the gestational age. Preeclampsia was diagnosed and classified according to strict criteria recommended by ACOG and National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy [15,16]: a systolic blood pressure of 140 mmHg or higher or a diastolic blood pressure of 90 mmHg or higher on two occasions at least six hours apart occurring after 20 weeks of gestation in a pregnant woman with previously normal blood pressure and detectable urinary protein ( 1 + by dipstick or  0.3 g/24 h). Severe preeclampsia was defined as a blood pressure  160/110 mmHg with either a urine dipstick showing 3+ or 4+ in a random urine sample or  5.0 g of proteinuria over 24 h. Other evidence of severe disease included increased serumcreatinine, eclampsia, pulmonary edema, oliguria (500 ml/24 h), fetal growth restriction, oligohydramnios and symptoms suggesting significant end-organ involvement (headache, visual disturbance or epigastric or right upper quadrant pain). Women who met criteria of preeclampsia but not severe preeclampsia were diagnosed mild preeclampsia.

TN-C measurements Blood samples were obtained from the cases to assess routine laboratory parameters and TN-C levels. For TN-C assessment, 5 ml of venous blood were drawn, centrifuged and the obtained sera were kept at 20  C until the time of use. The serum TN-C levels were measured by enzyme-linkedimmunoassay (ELISA) using ELISA kits (BIOABB, Human Tenascin-C Enzyme-linked Immunoassay kit, BIOABB, China, WuHan) in the Research Laboratory of the Biochemistry Department, Fırat University. Statistical analysis SPSS 21.0 was used for the statistical analysis of the obtained data. The data were expressed as mean ± SEM (standard error of the mean). The Kruskall–Wallis variance analysis was performed in order to determine the significance of the differences between the groups. For the values that were found to be significantly different (p50.05), the groups were compared in pairs using the Mann–Whitney U (MWU) test. The Bonferroni correction was performed in order to prevent significance inflation. The value of p50.017 was accepted as significant.

Results The sociodemographic features of the cases have been listed in Table 1. When Group 1 was compared with Groups 2 and 3, there was a significant difference in terms of birth weight (p50.017; MWU test). The white blood cell and platelet numbers, hemoglobin and hematocrit values and the biochemical parameters of the cases have been listed in Table 2.

Tenascin-C levels in preeclampsia

DOI: 10.3109/14767058.2014.998191

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Table 3. Comparison of the means of prepartum and postpartum serum tenascin-C levels of the groups. Group 1 (n ¼ 20) Tnc-Pre. (mg/ml) Tnc-Post. (mg/ml)

Group 2 (n ¼ 20)

1

5.02 ± 0.4 4.7 ± 0.11

2

12.8 ± 2.9 11.7 ± 1.82

Group 3 (n ¼ 20) 3

33.8 ± 11.7 50.6 ± 33.83

p value * *

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Values are expressed as mean ± SEM and %. *p50.05, KW variance analysis. The1,2,3 values show significant difference between the mean values. Values have been set in order from minimum to maximum (p50.017, MWU test). Tnc-pre: prepartum tenascin-C and Tnc-post: postpartum tenascin-C.

Figure 1. Comparison of tenascin-C levels measured in all groups (1, control; 2, mild preeclampsia; and 3, severe preeclampsia). TENPRE, prepartum tenascin-C; TENPOS, postpartum tenascin-C. 1, 2 and 3 show that there is a significant difference between the median values. The values have been set in order from minimum to maximum (p50.017, MWU test).

There was a significant difference between Group 1 and Groups 2 and 3 in terms of prepartum and postpartum TN-C levels (p50.017). There was also a significant difference in the prepartum TN-C levels between Groups 2 and 3 (p50.017). The relevant TN-C values are listed in Table 3 and Figure 1.

Discussion Our study has shown that the prepartum and postpartum TN-C levels are significantly higher in mild and severe preeclampsia than those in healthy pregnant women. As far as we know, this study is the first study in the literature studying the relationship between preeclampsia and the TN-C levels. The etiology of preeclampsia has not been fully clarified, and studies on the early diagnosis of this disorder still continue. The problem in the change of spiral arteries to uteroplacental vessels in preeclampsia, in other words, insufficient trophoblastic invasion, is also observed in cases of fetal growth restriction without maternal syndrome [17]. For this reason, trophoblastic invasion alone does not suffice for the development of maternal syndrome. Many studies have shown that in preeclampsia, there is an increase in placental oxidative stress and oxidative stress products in maternal circulation, but a decrease in antioxidant activity [18–20]. The cause of placental oxidative stress is the damage bestowed by hypoxia and ischemic reperfusion occuring as a result of disorders in spiral artery structuring. The free radicals released following oxidative stress cause lipid peroxidation and damage in

proteins and DNA [21]. The free radicals also cause apoptosis in trophoblasts [22]. These free radicals released after oxidative stress may enter the systemic circulation and lead to lipid peroxidation and oxidative damage in the vascular endothelium in the whole body [19]. The cause of maternal clinical symptoms in peeclampsia is systemic endothelial dysfunction [21]. There are many parameters indicating systemic endothelial damage in preeclampsia. In preeclamptic pregnant women, there is an increase in the serum levels of endothelial damage markers such as fibronectin, factor VIII antigen, thrombomodulin and vascular cell adhesion molecule [23,24]. Generally, in vitro studies have shown that there are many factors in cardiovascular diseases involving cytokines, angiotensin II and hemodynamic forces that cause a rearrangement in TN-C production [25]. The highest levels of TN are presented in placenta and skin in human tissues. Tenascin is highly expressed in the placental mesenchymal villi, which are considered the basis of growth and differentiation of the villous trees. Moreover, fibrinoid deposits at the surfaces of the villous trees are always separated from the fetal stroma by tenascin. The stroma of villi encased in fibrinoid is also positive for tenascin. This glycoprotein is also expressed in the villous stroma directly apposed to cell islands and cell columns. These data show that tenascin is expressed during the development of the placenta, particularly in the mesenchymal villi, cell islands and cell columns. These structures are considered to be the proliferating units of the villous trees. Tenascin underlying fibrinoid deposits suggests that it also participates in repair mechanisms. Thus, in the human placenta, tenascin expression can be correlated with villous growth, cell proliferation and fibrinoid deposition [26,27]. In addition to the narrowing of the spiral arteries, acute atherotic changes and formation of thrombus in the lumen may partially or completely stop the blood flow. It has been formerly reported that acute atherosis develops in the spiral arteries of uteroplacental circulation [28]. Wallner et al. have demonstrated the production of TN-C in human atherosclerotic plaque and have reported that TN-C levels increase with progression of the plaque. They have found minimal amounts of TN-C in early fibrous plaque and high levels of TN-C in lipid-rich plaque. In case of plaque rupture, residues of TN-C have been observed at the rupture sites. It has been observed that in plaques, TN-C is specifically localized at macrophage-accumulation sites intensely infiltrated with immune cells, but that TN-C is absent in adventitial and medial layers rich in smooth-muscle cells [12]. All these findings may show the contribution of TN-C in pathogenesis of preeclampsia.

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In our study, we have observed that the prepartum and postpartum TN-C levels are significantly higher in mild and severe preeclampsia than those in healthy pregnant women.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

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Tenascin C levels in patients with mild and severe preeclampsia.

To determine the serum tenascin-C (TN-C) levels in cases with mild and severe preeclampsia...
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