Middle East Fertility Society Journal (2015) xxx, xxx–xxx
Middle East Fertility Society
Middle East Fertility Society Journal www.mefsjournal.org www.sciencedirect.com
ORIGINAL ARTICLE
Use of serum leptin and insulin hormones levels as predictors of pregnancy outcome in pregnant women with history of recurrent early pregnancy loss Ayman Abd-Elaziz El-Dorf a,*, Ahmed Mohamed Eid Ossman a,1, Ahmed El-Sayed El-Halwagy a,2, Hesham Mohamed Borg a,3, Enaam Salah Abd-ElBar b,4 a Obstetrics & Gynecology Department, Faculty of Medicine, Tanta University, Tanta University Hospital, Elgeesh Street, Tanta, Egypt b Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta University Hospital, Elgeesh Street, Tanta, Egypt
Received 16 May 2015; revised 4 August 2015; accepted 19 August 2015
KEYWORDS Recurrent pregnancy loss; Leptin; Insulin
Abstract Aim: To evaluate levels of leptin and insulin in cases of unexplained early RPL in comparison with cases of previous normal pregnancies and suggest these levels as prognostic factors for the continuation of pregnancy beyond the 20th week. Methods: A prospective comparative controlled study was conducted at Obstetrics unit of Tanta University Hospital from Jan to Aug 2014 on 50 pregnant women who were divided into two groups: the study group included 25 cases with history of early RPL, and the control group included 25 cases with previous normal pregnancies. Serum levels of leptin and insulin were measured twice in both groups; at 5–8th and 10–12th week. Results: Leptin levels in ng/ml in the first sample were 9.414 ± 3.183 and 30.559 ± 10.672 in the control and study groups respectively with significant difference. As for the second sample, it was 11.672 ± 2.611 and 29.733 ± 9.133 in the control and study groups respectively with significant
* Corresponding author. Tel.: +20 01011156387. E-mail addresses:
[email protected] (A.A.-E. El-Dorf),
[email protected] (A.M.E. Ossman),
[email protected] (A.E.-S. El-Halwagy),
[email protected] (H.M. Borg),
[email protected] (E.S. Abd-ElBar). 1 Tel.: +20 1201513988. 2 Tel.: +20 1202224924. 3 Tel.: +20 1064412277. 4 Tel.: +20 1143540555. Peer review under responsibility of Middle East Fertility Society.
Production and hosting by Elsevier http://dx.doi.org/10.1016/j.mefs.2015.08.004 1110-5690 Ó 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: El-Dorf A-AE et al. Use of serum leptin and insulin hormones levels as predictors of pregnancy outcome in pregnant women with history of recurrent early pregnancy loss, Middle East Fertil Soc J (2015), http://dx.doi.org/10.1016/j.mefs.2015.08.004
2
A.A.-E. El-Dorf et al. difference. Insulin levels in llU/ml in the first sample were 18.075 ± 5.845 and 32.502 ± 13.057 in the control and study groups respectively with significant difference. In the second sample, on the other hand, it was 20.237 ± 4.944 and 34.128 ± 12.677 in the control and study groups respectively with significant difference. Leptin showed higher accuracy than insulin in prediction of early pregnancy loss. Conclusion: Higher levels of leptin and insulin were found in cases with early RPL especially in the aborted cases. The two hormones could be used as predictors of pregnancy continuation in these cases. Ó 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
1. Introduction Two or more failed clinical pregnancies before 20 weeks according to the American Society for Reproductive Medicine (ASRM) are defined as recurrent pregnancy loss (RPL). Before considering abortion, the biochemically diagnosed pregnancy must be documented by ultrasound and histological examination (1). Although there are different multiple etiologic factors for RPL, no apparent cause could be found in 50–75% of the cases (unexplained RPL) (2). There are only few evidencebased strategies for diagnosis and treatment of RPL. Intensive research for the cause behind RPL is pursued within immunological and genetic studies (3). Most of the published studies emphasized on the causes and treatment of unexplained RPL with little effort done for founding a predictor of pregnancy continuation in these cases (4). Leptin hormone was originally thought to be produced only by adipocytes to modulate satiety and energy (5). However, now it is known to be produced in many other tissues and is responsible for specific events in the reproductive maturity and fertility e.g. implantation, maternal physiological changes, regulation of conceptus development and fetal growth (6–8). Insulin resistance (IR) and hyperinsulinemia are incriminated as potential causes of the high rate of pregnancy loss and have been linked to the metabolic and endocrine abnormalities associated with the pathphisiologyology of RPL (9,10). Some studies suggested the use of leptin and insulin as predictors for pregnancy continuation beyond 20 weeks in cases of RPL (11). 2. Aim of the study The aim of this study was to evaluate levels of leptin and insulin in cases of unexplained early RPL in comparison with cases of previous normal pregnancies and to suggest these levels as prognostic factors for the continuation of pregnancy beyond the 20th week. 3. Patients and methods This prospective comparative controlled study was conducted in Tanta University Hospital, Obstetrics and Gynecology Department from January 2014 to November 2014. Seventy pregnant women were selected for the study after getting the approval of the hospital ethical committee and full explanation
of the study to the women who signed an informed written consent. Half of the selected women had previous two or more normal pregnancy and with no history of abortion, while the other half had a history of previous two or more consecutive first trimester miscarriage with the same partner, and all the previous pregnancy losses were documented by ultrasound and/or histological exam after uterine curettage. Cases of RPL were fully investigated and 35 cases were considered to have unexplained RPL based on the absence of apparent cause after the diagnostic workup (12) which included complete history taking & clinical examination, 2D & 4D ultrasound examination (for exclusion of anatomical malformation e.g. septum, fibroids, adenomyosis, polyps and intrauterine adhesions), hysterosalpingography and/or hysteroscopy, karyotypes of both partners, and the laboratory workup which included screening for diabetes, thyroid function tests, estimation of serum level of prolactin, basal FSH & LH, serum androgen, antiphospholipd antibodies, anticardiolipin antibodies, lupus anticoagulant, study of genetic thrombophilic mutations (factor V Leiden, prothrombin, methylenetetrahydrofolate reductase and Antithrombin III) and proteins C and S. The inclusion criteria for both groups included age between 20 and 35 years and viable singleton pregnancy between 5 and 12 weeks. The exclusion criteria for both groups included obesity, ectopic or molar pregnancy, patients with chronic diseases, and history of receiving any relevant hormonal treatment during or shortly before the current pregnancy, previous cervical cerclage and clinical evidence of genitourinary infection. Each pregnant woman was subjected to the following: Complete history taking, general examination, abdominopelvic ultrasound, and routine laboratory investigations. Three ml of fasting venous blood samples was collected from patients in both groups under aseptic precautions by venipuncture, then it was put in a clean plain test tube, after centrifugation, the separated serum was stored at 20 °C until the use. Serum levels of leptin and insulin hormone were measured twice using enzyme-linked immunosorbent assay (ELISA) technique. The first sample was taken at the 5–8th weeks of gestations and the second sample at the 10–12th weeks. Maternal serum leptin level was determined using the (DRGÒ Leptin ELISA (EIA-2395) kit which was a solid phase ELISA based on the sandwich principle. Maternal serum insulin level was determined using the (DRGÒ Insulin ELISA (EIA-2935) kit which was a solid phase ELISA based on the sandwich principle. Both were manufactured by DRG Instruments GmbH, Germany (13).
Please cite this article in press as: El-Dorf A-AE et al. Use of serum leptin and insulin hormones levels as predictors of pregnancy outcome in pregnant women with history of recurrent early pregnancy loss, Middle East Fertil Soc J (2015), http://dx.doi.org/10.1016/j.mefs.2015.08.004
Pregnant women with history of recurrent early pregnancy loss Follow-up of all patients was done up to 20 weeks to know the pregnancy outcome and the abortion was documented by ultrasound and histological examination if occurred. The outcome of the study is the evaluation of serum levels of leptin and insulin in both groups and correlation of these levels with the pregnancy outcome.
3 Table 3 ROC curve of both leptin and insulin as predictors of miscarriage in both groups.
Insulin Leptin
Cutoff point
Sens.
Spec.
PPV
NPV
Accuracy
>26.52 >14.06
60.0 92.0
100.0 96.0
100.0 95.8
71.4 92.3
0.811 0.982
4. Results The mean ± SD of maternal age in years in the control group was 28.12 ± 4.825, and in the study group 27.08 ± 4.102 with no significant difference between the two groups. The BMI in kg/m2 showed no significant difference in both groups as it was 25.821 ± 1.273 and 26.175 ± 1.404 in the control and study groups respectively. The gravidity showed no significant difference between the two studied groups while the parity was higher in the control group than the study group (P-value was 0.187). Leptin levels in both groups in the first and second samples are shown in Table 1, while the levels of insulin in both groups in the first and second samples are shown in Table 2. Twenty-nine patients (82.8%) in the control group completed 20th week of gestation compared to 13 patients (37.1%) in the study group. Six patients (17.1%) and 22 patients (62.8%) aborted in the control and study groups respectively with a significant difference between both groups (P-value < 0.05). In the aborted cases, higher leptin levels (>14.06 ng/ml) were found in 20 cases (90%) in the study group and 5 cases (83%) in the control group, while the higher levels of insulin (>26.52 llU/ml) were found in 13 cases (59%) in the study group and 3 cases (50%) in the control group. Three cases in the control group (8.5%) and another three cases (8.5%) in the study group showed higher levels of both leptin and insulin (>26.52 llU/ml) in both first and second sampling and completed 20 weeks. On the other hand, the aborted cases that showed higher levels of both leptin and insulin in both first and second sampling were 5 (14%) and 10 (28%) in the control and study groups respectively. The ROC curve of both leptin and insulin as predictors of miscarriage in both groups is shown in Table 3 and Fig. 1.
Table 1
5. Discussion We studied 97 cases of RPL and after the relatively extended and expensive laboratory and radiological investigations (for considering unexplained RPL) 35 patients were included in the final analysis; moreover, 17 eligible patients get aborted and refused to complete the study and are not included in the results. The selected patients for the study aged between 20 and 35 years to avoid the effect of age on the pregnancy outcome. Baban et al. (14) found a significant positive correlation between age and serum leptin levels in cases of RPL. Obese patients were excluded from the current study to avoid the effect of body fat on the leptin levels. However, in a study done by Wang et al. (15) no correlation was found between maternal plasma leptin levels and body mass index. Moreover, they mentioned that during pregnancy the BMI did not necessarily reflect body fat mass, and the remark-able increase of the serum leptin level was not explicable by an increase of fat mass alone. Laird et al.16 measured leptin in 53 patients with RPL: 23 of these women subsequently miscarried, 23 women had a term pregnancy while the other seven women had a preterm birth. Laird found that women who subsequently miscarried had significantly lower plasma leptin concentrations on both weeks 5– 6th and 7–8th of pregnancy than women who subsequently had a term birth; Laird suggested that leptin may play a role in preventing miscarriage. But more recently, Celik et al. (17) found a positive correlation between the number of previous miscarriages and leptin level, which is similar to the finding of the current study. Moreover, the aborted cases in the
Serum leptin levels in ng/ml in both groups.
Groups
Range
Mean ± SD
T
P-value
At 5–8th weeks
Control Study
5.24–15.34 13.01–44.43
9.414 ± 3.183 30.559 ± 10.672
9.494
