The Effects of Maternal Anticoagulant Therapy on Cord Blood Levels of VEGF-A and Soluble Flt-1 in Women with Recurrent Miscarriage

Abstract

Angiogenic imbalance of the placenta is one of the prominent pathophysiologic mechanisms leading to pregnancy complications like recurrent miscarriage. Low molecular weight heparin and low dose aspirin are frequently used in the management of recurrent miscarriages. Vascular endothelial growth factor (VEGF) and its soluble receptor-sFlt-1-plays a major role in angiogenesis. This study aims to investigate cord blood VEGF-A and sFlt-1 levels of women with recurrent miscarriages who receive anticoagulant treatment. Term newborns whose mothers were treated with LMWH and low-dose aspirin due to recurrent miscarriage were prospectively included. A control group consisted of healthy gestational age-matched infants who were born in the same period without an adverse perinatal outcome. The concentrations of VEGF-A and sFlt 1 in umbilical cord blood were assayed by ELISA and compared between the study and control groups. Forty-four infants with a maternal LMWH and low dose aspirin treatment during pregnancy and 42 healthy infants as a control group were included in the study. There were no significant differences in demographics, cord blood VEGF-A and sFlt-1 levels between the groups. There was also no correlation between the cumulative LMWH dosage and serum levels of these angiogenic factors. Cord blood VEGF-A and sFlt-1 levels were comparable in women with recurrent miscarriage under anticoagulant treatment and healthy subjects. Further studies are needed to compare women who have recurrent miscarriage with or without heparin treatment to better understand the effects of anticoagulant treatment on circulatory profile of cord blood angiogenic factors.

Keywords

• cord blood
• recurrent miscarriage
• heparin
• VEGF-A
• sFlt-1

References

1. 1. Allison JL, Schust DJ. Recurrent first trimester pregnancy loss: revised definitions and novel causes. Curr Opin Endocrinol Diabetes Obes 2009; 16: 446-50. http:// doi.org/10.1097/MED.0b013e3283327fc5
2. 2. Matthiesen L, Kalkunte S, Sharma S. Multiple pregnancy failures: an immunological paradigm. Am J Reprod Immunol 2012; 67 :334-340. http://doi.org/ 10.1111/j.1600-0897.2012.01121.x
3. 3. Rana S, Burke SD, Karumanchi SA. Imbalances in circulating angiogenic factors in the pathophysiology of preeclampsia and related disorders. Am J Obstet Gynecol 2020; S0002-9378 :31196-0. http://doi.org/10.1016/j.ajog.2020.10.022
4. 4. Elmahashi MO, Elbareg AM, Essadi FM, et al. Low dose aspirin and low-molecular-weight heparin in the treatment of pregnant Libyan women with recurrent miscarriage. BMC Res Notes 2014; 7: 23. http://doi.org/10.1186/1756-0500-7-23.
5. 5. Shaaban OM, Abbas AM, Zahran KM, et al. Low-Molecular-Weight Heparin for the Treatment of Unexplained Recurrent Miscarriage With Negative Antiphospholipid Antibodies: A Randomized Controlled Trial. Clin Appl Thromb Hemost 2017; 23: 567-572. http://doi.org/10.1177/1076029616665167
6. 6. Kwak-Kim J, Agcaoili MS, Aleta L, et al. Management of women with recurrent pregnancy losses and antiphospholipid antibody syndrome. Am J Reprod Immunol 2013; 69: 596-607. http://doi.org/10.1111/aji.12114
7. 7. Levine RJ, Maynard SE, Qian C, et al. Circulating angiogenic factors and the risk of preeclampsia. N Engl J Med 2004; 350: 672– 683. http://doi.org/10.1056/NEJMoa031884.
8. 8. Searle J, Mockel M, Gwosc S, et al. Heparin strongly induces soluble fms-like tyrosine kinase 1 release in vivo and in vitro--brief report. Arterioscler Thromb Vasc Biol 2011; 31: 2972-2974. http://doi.org/10.1161/ATVBAHA.111.237784.

9. 9. Rosenberg VA, Buhimschi IA, Lockwood CJ, et al. Heparin elevates circulating soluble fms-like tyrosine kinase-1 immunoreactivity in pregnant women receiving anticoagulation therapy. Circulation 2011; 124: 2543-2553. http://doi.org/10.1161/CIRCULATIONAHA.111.046821.
10. 10. Levesque BM, Kalish LA, Winston AB, et al. Low urine vascular endothelial growth factor levels are associated with mechanical ventilation, bronchopulmonary dysplasia and retinopathy of prematurity. Neonatology 2013; 104: 56-64. http://doi.org/ 10.1159/000351040.
11. 11. Catarino C, Rebelo I, Belo L, et al. Fetal and maternal angiogenic/anti-angiogenic factors in normal and preeclamptic pregnancy. Growth Factors. 2009 ;27: 345-351. http://doi.org/10.3109/08977190903184670
12. 12. Osol G, Moore LG. Maternal uterine vascular remodeling during pregnancy. Microcirculation 2014; 21: 38-47. http://doi.org/10.1111/micc.12080
13. 13. Shibuya M. Vascular Endothelial Growth Factor (VEGF) and Its Receptor (VEGFR) Signaling in Angiogenesis: A Crucial Target for Anti- and Pro-Angiogenic Therapies. Genes Cancer 2011; 2: 1097-1105. http://doi.org/10.1177/1947601911423031
14. 14. Andraweera PH, Dekker GA, Roberts CT. The vascular endothelial growth factor family in adverse pregnancy outcomes. Hum Reprod Update. 2012; 18: 436-457. http://doi.org/10.1093/humupd/dms011
15. 15. Kendall RL, Thomas KA. Inhibition of vascular endothelial cell growth factor activity by an endogenously encoded soluble receptor. Proc Natl Acad Sci U S A 1993; 90: 10705-10709. http://doi.org/10.1073/pnas.90.22.10705.
16. 16. Kappas NC, Zeng G, Chappell JC, et al. The VEGF receptor Flt-1 spatially modulates Flk-1 signaling and blood vessel branching. J Cell Biol 2008; 181: 847-858. http://doi.org/10.1083/jcb.200709114
17. 17. Brockelsby JC, Anthony FW, Johnson IR, et al. The effects of vascular endothelial growth factor on endothelial cells: a potential role in preeclampsia. Am J Obstet Gynecol 2000; 182: 176-183. http://doi.org/10.1016/s0002-9378(00)70510-2
18. 18. Clark DE, Smith SK, He Y, et al. A vascular endothelial growth factor antagonist is produced bythe human placenta and released into the maternal circulation. Biol Reprod 1998; 59: 1540-1548. http://doi.org/10.1095/biolreprod59.6.1540
19. 19. Pang L, Wei Z, Li O, et al. An increase inb vascular endothelial growth factor (VEGF) and VEGF soluble receptor-1 (sFlt-1)are associated with early recurrent spontaneous abortion. PLoS One 2013; 8: e75759. http://doi.org/10.1371/journal.pone.0075759
20. 20. Daponte A, Pournaras S, Polyzos NP, et al. Soluble FMS-like tyrosine kinase-1 (sFlt-1) and serum placental growth factor (PlGF) as biomarkers for ectopic pregnancy and missed abortion. J Clin Endocrinol Metab 2011; 96: E1444-51. , http://doi.org/10.1210/jc.2011-0037
21. 21. Kaitu'u-Lino TJ, Whitehead CL, Ngian GL, et al. Serum concentrations of soluble Flt-1 are decreased among women with a viable fetus and no symptoms of miscarriage destined for pregnancy loss. PLoS One 2012; 7: e32509. http://doi.org/10.1371/journal.pone.0032509
22. 22. Muttukrishna S, Swer M, Suri S, et al. Soluble Flt-1 and PlGF: new markers of early pregnancy loss? PLoS One 2011; 6: e18041. http://doi.org/ 10.1371/journal.pone.0018041
23. 23. Pang LH, Li MJ, Li et al. Vascular endothelial growth factor (VEGF) and the VEGF soluble receptor-1 (sFlt-1) in chorionic villus tissue from Chinese women with early recurrent spontaneous abortion. J Int Med Res 2011; 39: 830-837. http://doi.org/10.1177/147323001103900316
24. 24. Wang G, Zhang R, Li C, et al. Evaluation of the effect of low molecular weight heparin in unexplained recurrent pregnancy loss: a meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med. 2021: 1-8. http://doi.org/10.1080/14767058.2021.1957819
25. 25. Kaandorp SP, Goddijn M, van der Post JA et al. Aspirin plus heparin or aspirin alone in women with recurrent miscarriage. N Engl J Med 2010; 362: 1586-1596. http://doi.org/ 10.1056/NEJMoa1000641
26. 26. Clark P, Walker ID, Langhorne P, et al. SPIN (Scottish Pregnancy Intervention) study: a multicenter, randomized controlled trial of low-molecular-weight heparin and low-dose aspirin in women with recurrent miscarriage. Blood 2010; 115: 4162-4167. http://doi.org/10.1182/blood-2010-01-267252
27. 27. Nelson SM, Greer IA. The potential role of heparin in assisted conception. Hum Reprod Update 2008; 14: 623-645. http:doi.org/10.1093/humupd/dmn031
28. 28. Norrby K, Nordenhem A. Dalteparin, a low-molecular-weight heparin, promotes angiogenesis mediated by heparin-binding VEGF-A in vivo. APMIS 2010; 118: 949-957. http://doi.org/10.1111/j.1600-0463.2010.02635.x
29. 29. Hagmann H, Bossung V, Belaidi AA, et al. Low-molecular weight heparin increases circulating sFlt-1 levels and enhances urinary elimination. PLoS One 2014; 9: e85258. http://doi.org/ 10.1371/journal.pone.0085258
30. 30. Sela S, Natanson-Yaron S, Zcharia E, et al. Local retention versus systemic release of soluble VEGF receptor-1 are mediated by heparin-binding and regulated by heparanase. Circ Res 2011; 108: 1063-1070. http://doi.org/10.1161/CIRCRESAHA.110.239665.
31. 31. Denizot Y, Leguyader A, Cornu E, et al. Release of soluble vascular endothelial growth factor receptor-1 (sFlt-1) during coronary artery bypass surgery. J Cardiothorac Surg 2007; 2: 38. http://doi.org/10.1186/1749-8090-2-38
32. 32. Moore KH, Chapman H, George EM. Unfractionated heparin displaces sFlt-1 from the placental extracellular matrix. Biol Sex Differ 2020; 11: 34. http://doi.org/10.1186/s13293-020-00311-w
33. 33. Park M, Lee ST. The fourth immunoglobulin-like loop in the extracellular domain of FLT-1, a VEGF receptor, includes a major heparin-binding site. Biochem Biophys Res Commun 1999; 264: 730-734. http://doi.org/10.1006/bbrc.1999.1580