A study of serum homocysteine levels during normal pregnancy and preeclampsia

A STUDY OF SERUM HOMOCYSTEINE LEVELS DURING NORMAL PREGNANCY AND PREECLAMPSIA

Dissertation submitted to

The Tamil Nadu Dr. M.G.R Medical University, Chennai In fulfilment of the requirements for the award of the degree of

M.S. OBSTETRICS & GYNAECOLOGY

Under the guidance of

Dr. REENA ABRAHAM MD, DGO.,

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

PSG INSTITUTE OF MEDICAL SCIENCES & RESEARCH, COIMBATORE

THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY, CHENNAI, TAMILNADU

ENDORSEMENT BY THE HOD, DEAN / HEAD OF THE

INSTITUTION

This is to certify that the dissertation entitled, “A STUDY OF SERUM

HOMOCYSTEINE LEVELS DURING NORMAL PREGNANCY AND PREECLMPSIA” is the bonafide original research work of Dr. DIVYA S under

the guidance of Dr.REENA ABRAHAM Professor, Department of Obstetrics and

Gynecology, P.S.G IMSR, Coimbatore in partial fulfillment of the requirement for

the degree of Master of Surgery in Obstetrics and Gynecology.

Seal and Signature of the HOD Seal and Signature of the Dean

Dr. SEETHA PANICKER M.D, D.G.O, Dr. RAMALINGAM,

Professor & HOD, PSG IMSR, Coimbatore,

Department of Obstetrics and Gynecology

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled, “A STUDY OF SERUM

HOMOCYSTEINE LEVELS DURING NORMAL PREGNANCY AND PREECLAMPSIA” is a bonafide original work of Dr.DIVYA S, in partial fulfillment of the regulations of The Tamil Nadu Dr. M.G.R Medical University

for the award of MS degree in Obstetrics and Gynecology.

Signature of the guide

Dr. REENA ABRAHAM MD, DGO.,

Professor,

Department of Obstetrics and Gynecology,

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A STUDY OF SERUM

HOMOCYSTEINE LEVELS IN NORMAL PREGNANCY AND

PREECLAMPSIA” is a bonafide and genuine research work carried out by me

under the guidance of Dr. REENA ABRAHAM MD, DGO., Professor,

Department of Obstetrics and Gynecology, P.S.G IMSR, Coimbatore.

This dissertation is submitted to The Tamil Nadu Dr. M.G.R Medical

University in fulfillment of the University regulations for the award of DM degree

in Cardiology. This dissertation has not been submitted for award of any other

degree or diploma.

Signature of the Candidate

COPYRIGHT DECLARATION BY THE CANDIDATE

I, Dr. DIVYA S hereby declare that The Tamil Nadu Dr. M.G.R Medical University, Chennai shall have the rights to preserve, use and disseminate this

dissertation in print or electronic format for academic / research purpose.

Signature of the Candidate

CERTIFICATE – II

This is to certify that this dissertation work titled A STUDY OF SERUM

HOMOCYSTEINE LEVELS IN NORMAL PREGNANCY AND

PREECLAMPSIA of the candidate Dr. DIVYA S with Registration

Number 221416451 for the award of MASTER IN SURGERY in the branch of

OBSTETRICS & GYNAECOLOGY. I personally verified the urkund.com website for the purpose of plagiarism Check. I found that the uploaded thesis file

contains from introduction to conclusion pages and result shows 0% of plagiarism

in the dissertation.

ACKNOWLEDGEMENT

It gives me immense pleasure to express my heartfelt and profound sense of

gratitude to my respected teacher and guide, Professor Dr. Reena Abraham for

her valuable suggestions, meticulous guidance, support and encouragement in

doing this study.

I am grateful to Professor Dr. Seetha Panicker, Professor Dr.Chitra for their

invaluable help in preparing this dissertation. I am thankful to Dr. Karthikeyan,

Assistant Professor, Department of Community Medicine for helping with the data

analysis and statistics.

As he is always, the wind beneath my wings, my husband Dr.Prasanna Kumar, a

big thank you for perfecting and correcting my sentences and language and for

your constant support and encouragement.

I would also like to extend my gratitude to the entire Department of Obstetrics &

CONTENTS

NO. TOPIC

PAGE NO.

1. INTRODUCTION 1

2. AIMS AND OBJECTIVES 7

3. REVIEW OF LITERATURE 8

4. MATERIALS AND METHODS 50

5. RESULTS 53

6. DISCUSSION 78

7. LIMITATIONS 87

8. CONCLUSION 88

9. REFERENCES

1

INTRODUCTION

Hypertensive disorders complicate upto 10% of all pregnancies.

Preeclampsia is one of the major causes for morbidity and mortality (1). Despite a

fairly high incidence, the etiology underlying preeclampsia is still incomplete. The

three major theories of preeclampsia are endothelial dysfunction, inflammation and

angiogenesis. Majority of the adverse outcomes can be avoided with proper

identification of high risk patients and proper management during antenatal period.

Homocysteine is a sulphur containing amino acid which is formed from

methionine that is involved in methylation and sulphuration pathways such as lipid

peroxidation and oxidative stress. Blood concentration of homocysteine is

determined by folic acid and Vitamin B12.

Hyperhomocysteinemia is associated with vascular disease. In normal

pregnancy homocysteine concentration falls(2). Alteration in maternal and fetal

homocysteine causes fetal neural tube defects and placental vasculopathy which

leads to preeclampsia, abruption and recurrent pregnancy loss. Oxidative stress and

endothelial dysfunction caused by hyperhomocysteinemia leads to preeclampsia.

In bio humoural parameters homocysteine has recently been considered a possible

cause of vascular damage. Hyperhomocysteinemia in early pregnancy may

2

Prediction, prevention, early diagnosis and treatment and providing optimal

health care to all hypertensive patients are necessary to achieve the millennium

developmental goals. Therefore a case control study was designed to examine

serum homocysteine in normal pregnancy and preeclampsia and its association

with the severity of preeclampsia

HISTORY OF HOMOCYSTEINE

Carson and Neil in 1962, for the first time suggested the association between

elevated serum homocysteine and diseases. A new and rare inborn error of

methionine - homocysteine metabolism is associated with increased urinary

excretion of homocysteine. Homocysteinuria was found in mentally retarded

children in USA and also in Ireland simultaneously. Then subsequently

cystathionine beta synthase deficiency was identified in 1964 by Mudd et al (3)in

the liver biopsy of a patient with homocysteinuria. Gibson et al(4) 2 years later

noted that the homozygous defect of the cystathionine beta synthase was associated

with increased risk of death in young children. In the same year

hyperhomocystenemia causing vascular changes and thrombosis was also

3

McCully(5) hypothesized that elevated homocysteine causes vascular changes

which lead to thrombosis and he also identified the link between homocysteine and

cardiovascular disease. He also said that hyperhomocysteinemia causes

arteriosclerosis, since it is disorder of the sulphur containing amino acid which

leads to accumulation of homocysteine and causes vascular changes.

In 1976 Wilcken and Wilcken confirmed that patients with coronary artery

disease had increased levels of cysteine-homocysteine after a methionine loading

test in comparison with the controls.

An international survey of 629 patients with cystathionine beta synthase

deficiency found that they had a 50% risk of suffering from thromboembolic

events before the age of 30 years. Large scale studies have been done on

hyperhomocysteinemia and cardiovascular disease in 1990’s.

Atherothrombotic disease has drawn the attention of scientists from many

fields. Herrmann et all in 2001 found that hyperhomocysteinemia is a risk factor

for cardiovascular diseases, pregnancy complications, neuropsychological

5

The percentage of each form of homocysteine is as follows: Reduced form of Homocysteine

Homocysteine is about 1-2%

OXIDIZED FORM OF HOMOCYSTEINE Free forms:

Homocysteine (5-10%)

Homocysteine – cysteine (5-10%)

Protein bound:

Protein –homocysteine (80-90%)

6

The non protein amino acid homocysteine is a byproduct of degradation of

methionine into non essential thiol cysteine. Methionine is a protein forming

amino acid which is obtained by two ways, mainly by food intake or remethylation

7

AIMS AND OBJECTIVES

To find any correlation between serum Homocysteine level in preeclampsia

and normal pregnancy.

To know the severity of preeclampsia, whether it is mild or severe

depending upon the elevated Homocysteine levels.

This study was done mainly to look for the presence of elevated serum

homocysteine levels in preeclampsia in our population. High prevalence of

hyperhomocysteinemia is present in our population. About 54.5% of the

population has MTHFR enzyme polymorphism.

Elevated homocysteine levels have been recently studied in pregnant

patients as it is associated with several pregnancy related complications and

8

REVIEW OF LITERATURE

HOMOCYSTEINE METABOLISM:

Homocysteine is a naturally occurring Sulphur containing amino acid.

Homocysteine metabolism stands at the intersection of two pathways:

a) Remethylation

Remethylation of homocysteineto methionine which requires vitamin B 12

and folate.

b) Transsulfuration

Transulfuration of homocysteine to cystathionine which requires vitamin B 6

REMETHYLATION PATHWAY

In this homocysteine acquires a methyl group from N5–Methyl

tetrahydrofolate (MTHFR) or from betaine to methionine. This reaction occurs in

all tissues and it is Vitamin B12 dependent, whereas the reaction with betaine is

confined mainly to the liver and it is not dependent on Vitamin B12. A proportion

of methionine is activated by ATP adenosine triphosphate to S adenosylmethionine

(SAM). SAM serves as a methyl donor to a variety of acceptors like

guanidinoacetate, nucleic acids, neurotransmitters, phospholipids and hormones. S-

9

subsequently hydrolyzed and the regenerated homocysteine now becomes

available to start a new cycle of methyl transfer group. This hydrolysis reaction is

reversible and favours the synthesis of SAH.

TRANSSULFURATION PATHWAY:

In transsulfuration pathway homocysteine condenses with serine to form

cystathionine. It is an irreversible reaction which is catalyzed by a Vitamin B6

containing enzyme, cystathionine synthase. Cystathionine is hydrolyzed by a

second vitamin B6 containing enzyme - cystathionase to form cysteine and alpha

ketobutyrate. Excess cysteine is oxidized to inorganic sulphates or taurine and is

excreted in the urine. In addition to the synthesis of cysteine, the transsulfuration

pathway effectively catabolizes the excess homocysteine which is not needed in

methyl transfer.

Homocysteine is not a dietary constituent. The sole source of homocysteine

is methionine. The primary source of methionine is from dietary protein, mainly

derived from animal proteins, however methionine is also supplied from proteins

within the body, mainly due to muscle mass turnover. Plasma normally contains a

small amount of homocysteine averaging about 5 to 15 micro mol/L, which is

10

This mechanism complements the catabolism of homocysteine through

transsulfuration pathway and altogether these mechanisms help to maintain a low

11

Hyperhomocysteinemia indicates that the homocysteine metabolism is in

some way disrupted and the export mechanism is producing excessive

homocysteine into the blood. The export mechanism to some extent limits the

intracellular toxicity, but the vascular tissue is exposed to excess homocysteine

which leads to deleterious effects.

In the first step of the Meth adenosyltransferase catalysis the transfer of

adenosine from ATP to Methionine yields a high energy compound that is S

adenosylmethionine. This methyl group can be transferred to a wide range of

12

to several metabolic processes, in particularly the methylation of DNA which is

important in the regulation of gene expression.

About 100 methyl transferases exist of which most of them are subjected to

potent feedback inhibition by the product of the methyl transfer group, S-

adenosylhomocysteine. S–adenosylhomocysteine is quickly removed by the

process of hydrolysis which forms homocysteine and adenosine. Under

physiological conditions the enzyme which is responsible is

S-adenosylhomocysteine which actually favours reverse condensation reaction. In

vivo, the reaction is driven forward to produce homocysteine by effectively

removing adenosine by adenosine kinase and adenosine deaminase.

Vitamins are important cofactors for the subsequent reactions in

homocysteine metabolism. Therefore nutritional deficiencies because of poor diet

or malabsorption can cause disturbances within the pathway. The fate of

homocysteine is governed by the availability of the methionine from the diet. If

methionine is deficient then the transfer of a methyl group from a donor compound

brings about the remethylation of homocysteine. In most of the tissues the reaction

involves 5 methyltetrahydrofolate as a donor compound and vitamin B12 acts as a

13

Methionine synthase metabolizes the methyl group from

5- methyltetrahydrofolate which channels one carbon unit derived from formate

and aminoacids such as serine, glycine and histidine into the methylation cycle,

which provides the methyl group for the synthesis of S – adenosinemethionine.

Serine and glycine hydroxymethyltransferase, methylenetetrahydrofolate

dehydrogenase and methylenetetrahydrofolate reductase serve to regenerate 5

methylenetetrahydrofolate from tetrahydrofolate.

Most of the body’s cells contains methionine synthase, however some

tissues like liver and kidneys exhibits alternate remethylation pathways which

utilizes betaine that is trimethylglycine as a methyl donor instead of 5-

methyltetrahydrofolate.

Sometime when methionine is present abundantly, homocysteine enters the

transulfuration pathway, where it undergoes a condensation reaction with serine to

form cystathionine. Vitamin B6 acts as a cofactor for the enzyme cystathionine β

synthase.

Cysteine is formed by the hydrolysis of cystathionine by γ- cystathinase, the

byproduct of which is  - ketobutyrate. Cysteine is used for the synthesis of

14

Sulphur is excreted 70 % via urine by oxidation of the Sulphur atom of cysteine as

an inorganic sulphate.

S – adenosylmethionine acts upon the key enzymes . The abundance of

S-adenosylmethionine promotes the transulfuration pathway by its negative allosteric

effect on methytetrahydrofolate by blocking remethylation and a positive allosteric

effect on cystathionine β synthase, which allows the removal of excessive

methionine and homocysteine. If the S adenosylmethionine levels are low then the

allosteric regulation is removed, enters the remethylation pathway and methionine

is regenerated.

The oxidized ferric state of hemoglobin is more favourable to homocysteine

binding, possibly conformational changes in the proteins. Under oxidative stress

homocysteine is channeled into the regeneration of depleted glutathione through

transulfuration pathway.

Homocysteine metabolism is very complex which involves enzymes, B

vitamins and folate. Deficiency in the supply or functioning of any of these

15

The cellular folate cycle is shifted towards the formation of methyl

tetrahydrofolate. Utilization of the Methionine for purine and pyrimidine

biosynthesis is reduced. Methionine rich diet increases SAM levels within the

cells. SAM acts as an allosteric inhibitor for MTHFR betaine: homocysteine

methyltransferase causing aberration in the remethylation pathway.

SAM level causes an increased cellular SAH concentration which is a

strong inhibitor of the adenosylmethionine dependent methyl transferase.

Homocysteine is recycled to Meth several times and it becomes irreversibly

16 FOLATE

Folate is a water soluble vitamin B which acts as a coenzyme to accept or

donate one carbon unit needed in several metabolic pathways. The name folic

acid is derived from Latin word folium. It was first identified from spinach leaves

in 1941 and was synthesized in 1946.

The chemical name of folic acid is pteroylmonoglutamic acid. Naturally

occurring dietary folate contains pteridine ring and polyglytamate polypeptide

which is hydrolyzed in the intestinal lumen into monoglutamate. Oxidized form of

folic acid is only present in tablet form, fortified food and in multivitamin tablets.

17

The first step in the folate cycle is the conversion of tetrahydrofolate to

5,10-methylene-THF using serine as a source of carbon units and Vit B6 dependent

serine hydroxy methyl transferase enzymes. The cell proliferation and DNA

synthesis requires transfer of one carbon atom, this is the main fundamental

function of folic acid. Carbon atoms are passed on for the synthesis of purines and

pyrimidines. Hence, folate deficiency leads to megaloblastic anemia,

reticulocytopenia, thrombocytopenia, and leukopenia, all of which are reversible

after folic acid supplementation and reintroduction into diet. Biochemical status to

assess the folate status are serum and RBC folate levels.

Serum folate is a circulating folate, which can change quickly and is

influenced markedly by diet. RBC folic acid status is intracellular, which gets

accumulated during erythropoiesis and it is retained throughout RBC life span.

RBC folate is the most representative of body stores of folate, in the absence of

pernicious anemia.

The main regulator of homocysteine degradation is folate cycle.

Methyltetrahydrofolate is the only circulating form of folate which is used for the

premethylation of homocysteine to Methionine. Folate, Vit B12 and Methionine

synthase work together within the cell. Fasting plasma homocysteine is increased

18

Homocysteine level is usually normal in Vit B6 deficient subjects. The

genetic defect of Methionine synthase and Vit B12 deficiency leads to increased

level of Methyltetrahydrofolate. The consequences are abnormal intracellular

folate level in the presence of normal or increased circulating folate levels. The

blot THF regeneration leads to reduced thymidylate synthesis causing

megaloblastic anemia.

HYPERHOMOCYSTEINEMIA

Abnormal elevation of homocysteine levels, above 90thor 95th percentile of

the corresponding reference group is known as hyperhomocysteinemia. Normal

range of homocysteine is 5-12micro mol/l. In antenatal patients generally

homocysteine levels fall due to hemodilution and also folic acid intake by patients.

In pregnancy 5-7 micro mol/l is considered as normal. Anything above this level is

considered as hyperhomocysteinemia in pregnancy.

In non – pregnant population:

Moderate hyperhomocysteinemia is defined as homocysteine concentration

levels between 12- 30 micro mol/l. Seen in mild folate and Vit B12

19

Intermediate hyperhomocysteinemia is defined as serum homocysteine

concentration between 30-100 micro mol/l. Seen in moderate to severe folate

and Vit B12 deficiency and also with renal failure.

Severe hyperhomocysteinemia is defined as serum homocysteine

concentration more than 100 micro mol/l. Seen in severe Vit B12 deficiency.

In normal pregnancy homocysteine levels are lower when compared to the

non pregnant state. Thus these values cannot be applied to pregnant women which

becomes misleading. Till date no value is available as a cut-off value of

homocysteine in pregnant women. Homocysteine value less than 5-7 micro mol/l

in normotensive pregnant women who had adequate folate and Vit B12 was

20

HYPERHOMOCYSTENEMIA CAUSED BY FOLIC ACID DEFICENCY

Folic acid deficiency causes decreased synthesis of methionine, which leads

to the metabolism of homocysteine to transulfuration pathway. The decreased

synthesis of methionine causes decreased synthesis of SAM concentration. N 5

tetrahydofolate deficiency causes N – Methyltranferase to be fully active, which

further decreases the SAM level and increases the synthesis of serum

homocysteine which is a byproduct of glycine methylation.

So the transulfuration pathway becomes ineffective due to increased

homocysteine concentration in addition to decreased level of SAM, which is too

low to activate cystathionine synthesis. As a result homocysteine accumulates in

the blood which leads to hyperhomocystenemia.

FACTORS INFLUENCING HYPERHOMOCYSTENIEMIA

The regulation of Methionine cycle and Homocysteine pathway is associated

with the availability of folate, Vit B6 and Vit B12. Folate donates its methyl for

remethylation of homocysteine.

There are many other factors influencing Homocysteine which is classified as:

Physiological determinants: sex, race, age and pregnancy.

21

Genetic factors: methionine synthase reductase enzyme, CBS enzyme,

MTHR enzyme.

Drugs : hormones, antiepileptic drugs, lipid lowering drugs

AGE AND GENDER:

Advanced age and male gender are found to be associated with

hyperhomocysteinemia. This may be due to difference in the status of vitamins

between different age groups and gender. Homocysteine levels may also be altered

and may be related to muscle mass, hormonal factors and renal function.

Homocysteine levels were found to be high in women who are post menopausal

when compared to perimenopausal women. In pregnant women homocysteine was

found to be lower than the non pregnant women.

DIETARY FACTORS

Several studies have provided evidence of the importance of vitamin B in

homocysteine metabolism. A metaanalysis of 12 RCT’s showed that folic acid

supplementation had decreased the homocysteine levels in serum by 25%, with the

dosage of 0.5 to 5 mg. However higher pretreatment of homocysteine showed

reduced level of homocysteine in response to folic acid treatment. Vitamin B6 and

B12 are not utilized in homocysteine metabolism, but they function as a cofactors

22 LIFESTYLE FACTORS

In a cohort study conducted by Caerphilly et al showed that smokers had

significantly elevated homocysteine level than non smokers. Following cessation

of smoking, homocysteine value returns to normal.

Smoking itself can affect the metabolism of Vitamin B, which leads to

abnormal homocysteine metabolism. Generally smokers consumes more of an

unhealthy diet than non smokers.

Chronic alcoholism causes hyperhomocysteinemia due to low levels of

vitamin B and it is also influenced by the irregularity of the feeding patterns. It is

believed that acetaldehyde which is a metabolite of ethanol forms a covalent bond

with the proteins that inhibit MS activity.

Folate deficiency also causes hyperhomocystenemia in alcoholics. Mild

alcohol consumption reduces the serum homocysteine levels as observed by

Hordaland cohort.

Caffeine intake causes hyperhomocysteinemia. Caffeine interferes with

23 PREGNANCY

Homocysteine level decreases during pregnancy which is independent of

folate status, and it becomes normal within 3 to 4 days of the postnatal period.

Reason for this low level of homocysteine is not clear. Studies say that it may be

an adaptation to maintain the placental circulation. Fetus is also is involved in the

uptake of maternal homocysteine.

DISEASES

The basis of hyperhomocysteinemia in renal failure is not clearly

understood, although several processes explain the close correlation between

hyperhomocysteinemia and renal function.

The most common cause of hyperhomocysteinemia other than nutritional

deficiency of vitamin B12 and folate is renal failure. Cancer is associated with

higher levels of homocysteine. Type II DM who are on metformin, can have mild

hyperhomocysteinemia. Gastro intestinal disorders like ulcerative colitis, Crohns

disease and IBS leads to malabsorption of vitamin B12 and folate, which in turn

24 MEDICATIONS:

Sex steroid hormones have influence on homocysteine levels. It was found

that tamoxifen which is an anti oestrogen was found to decrease the serum

homocysteine concentration.

Drugs like methotrexate which inhibits the conversion of dihydrofolate to

tetrahydrofolate decreases the synthesis of DNA, RNA nucleotides. Since

methotrexate inhibits cell proliferation, it is used in the treatment of cancer,

psoriasis and rheumatoid arthritis.

Phenytoin causes folic acid deficiency. Drugs like carbamazepine,

pyrimidone and sodium valproate also interfere with remethylation of

homocysteine.

Metformin and theophylline decreases the B vitamin concentration which

increases the serum homocysteine concentration. The drugs which acts as B6

antagonist are isoniazid, cyloserine, procarbazine, hydralazine and phenelzine also

causes increase in serum homocysteine levels.

Drugs which have a free thiol group like N – acetylcysteine and D

penicillaminecan be used to decrease serum homocysteine concentration in patients

25 GENETIC FACTORS:

Cystathionine beta synthase:

Mutation in this enzyme leads to homocysteinuria which was published by

Gaustadnes et al in 1998. It is an autosomal recessive disease, in which it was

found that there was elevation of serum homocysteine and also excretion of

homocysteine in urine. There is luxation of optic lenses due to disruption of the

zonularfibres, seen in children who have homocystinuria and who are aged

between 2 to 10 years. It may also be associated with mental retardation,

psychiatric illness, skeletal abnormalities and osteoporosis.

Methyltetrahydrofolatereductase (MTHFR):

These are rare inborn errors of metabolism. Mutation of

methyltetrahydrofolate causes weak effect on the enzymes. The prevalence of

these mutations are high in general population. MTHFR catalyzes the formation of

5-methyl THF from 5,10methylene tetrahydrofolate. The folate from the above

reaction is necessary for the remethylation of homocysteine to methionine. Higher

homocysteine levels are found in subjects with marginal folate status. MTHR itself

is not the reason for venous thrombosis but it is reported that it decreases the bone

26

PATHOGENESIS IN HOMOCYSTEINE INDUCED THROMBOSIS

Hyperhomocysteinemia causes both arterial and venous thrombosis, which

causes stroke, myocardial infarction, pulmonary embolism and retinal vein

thrombosis. Hyperhomocysteinemia also causes other diseases like preeclampsia,

recurrent pregnancy loss, IUGR, preterm delivery, abruptio placenta and it also

associated with neural tube defects.

Russel Rose proposed a hypothesis on hyperhomocysteinemia causing

endothelial dysfunction, which alters the normal homeostatic response of the

endothelium. Hence endothelial injury causes adhesion of leukocytes and platelets

and also an increase in the vascular permeability. This causes the endothelium to

have procoagulant property.

Due to inflammation cytokines and other inflammatory factors there is

further damage and focal necrosis. All these changes leads to proliferation of

smooth muscle and formation of fibrous tissue which prevents further dilatation of

27

The influence of hyperhomocysteinemia on endothelial function:

The effect of homocysteine is the reduction in the endothelial function.

Endothelial cells secrete several agents involved in vasoconstriction and

vasodilatation. Endothelium derived vasoconstrictors are thromboxane A2,

prostaglandins H2 and endothelin 1. The endothelium derived vasodilators are

nitric oxide and prostacyclin. Homocysteine mediates the endothelial dysfunction.

Homocysteine reduces the bioactivity of nitric oxide; the reaction of nitric

oxide with superoxide produces peroxynitrite which is a potent oxidant which

causes activation of polymerase, which is a mediator of vascular dysfunction in

disease. Superoxide can oxidize tetrahydrobiopterin which is a co factor for Nitric

Oxide synthase leading to reduced activity of eNOS where the electrons are

transported to molecular oxygen forming O2 rather than to L arginine forming

Nitric Oxide. Homocysteine inhibits the activity of eNOS by increasing the levels

of asymmetric dimethylarginine, which is an inhibitor of NO synthase which leads

to reduce the bioavailability of NO.

Homocysteine increases the oxidative stress and increase the levels of

reactive oxygen species. Elevated Homocysteine levels inhibit the expression and

function of antioxidant enzymes such as extracellular superoxide dismutase by

28

Homocysteine increases the vascular sources of O2 including xanthine oxidase,

cyclooxygenase, nitric oxide synthase.

Homocysteine can upregulate the components of the inflammatory cascade.

Homocysteine activates nuclear factor B, which causes overexpression of

cytokines leading to inhibition of vasoconstriction, thereby leading to impairment

of endothelial function. TNF alpha increases the activity of NADPH oxidase

causing consequently increased superoxidase levels in Hyperhomocysteinemia.

The influence of homocysteine on smooth muscle and extracellular matrix:

Homocysteine causes proliferation of smooth muscles, which is inhibited by

folic acid. Homocysteine causes accumulation of collagen. When vascular smooth

muscle is exposed to homocysteine, cytokine stimulation occurs which leads to

production of NO and leads to early atherosclerosis. Hyperhomocysteinemia

causes thrombosis which explains homocysteine associated illness which was

already mentioned.

The influence of homocysteine on the coagulation system:

Homocysteine induces the activity of TF in the endothelial cells and also in

the monocytes and peritoneal macrophages, which triggers the coagulation system.

Homocysteine increases the platelet activation and aggregation. Stimulation of

29

homocysteine indirectly inhibits the Nitric oxide production. Nitric oxide

inhibition can also be due to endogeneous inhibition of nitric oxide synthase and

asymmetric dimethylarginine.

Undas et al suggested the impaired inactivation of factor Va by activated

protein C due to homocysteinylation of the cofactor by modification of free

cysteine. Factor VII a and thrombin activities are increased in patients with

coronary artery disease, but Bos et al suggested that increased risk of venous

thrombosis in hyperhomocysteineima is not reflected by an increased endogenous

thrombin potential.

Impaired fibrinolysis is an important mechanism for thrombosis

predisposition in hyperhomocysteinemia. Homocysteine possesses anti fibrinolytic

properties, which enhances the binding of lipoprotein to fibrin and causes

inhibition of tissue plasminogen activator to the endothelial cell through annexin

II. Hyperhomocysteinemia favours thrombogenesis. To prove this clinical studies

have been performed in hyperhomocysteinemic patients. Some studies provide

30

HOMOCYSTEINE IN NORMAL PREGNANCY AND PREGNANCY COMPLICATED WITH PREECLAMPSIA:

Preeclampsia is the most common cause of maternal morbidity and mortality

in developing countries.

Preeclampsia is a two stage disease:

STAGE 1: It is characterized by the reduction in the placental perfusion.

STAGE 2: It denotes the maternal syndrome in which hypertension is accompanied with proteinuria. Oxidative stress is the most important factor for the

progression of the disease. Along with other maternal factors like age, twin

pregnancies, nulliparity, oxidative stress and endothelial dysfunction is the main

pathogenesis of preeclampsia. The etiology of preeclampsia is still not clearly

understood.

The genetic makeup and acquired factors are reasons for the disease

occurrence and progression. The nutritional demands are high in pregnancy, hence

it is associated with higher vitamin B requirements for both the mother and the

growing fetus.

Vitamin B includes folate, Vitamin B12 and Vitamin B6 which acts as a

31

division. Serum concentration of these vitamins decreases during pregnancy. The

low concentration of these vitamins is due to higher metabolic rate and increased

active transport of the vitamins to the fetus through the placenta.

Maternal concentration of these vitamins even from the preconceptional

period affects the serum concentration of these infants at birth. A study conducted

by Casterline and et al, measured the vitamin levels from the breast milk in women

who are lactating and found that 31% of mothers had low vitamin B12 and 61 % of

32

Maternal nutritional status influences the outcome of pregnancy. Decreased

folate levels in the mother is associated with preterm delivery, low birth weight

and neural tube defects. Vitamin B12 deficiency is associated with recurrent

abortion, neural tube defects and megaloblastic anemia.

Therefore folic acid supplementation pre conceptionally reduces the chances

of neural tube defects by 30 %. In addition to this, folic acid supplementation also

reduces the incidence of preeclampsia and gestational hypertension.

Elevated serum homocysteine levels indirectly denotes the deficiency of B

vitamins. Maternal hyperhomocysteinemia affects both the mother and the fetus

(Vollestet all 2000).

A study was conducted by Murphy et al(8), where they included 93 women

and their off springs, found that fetal Homocysteine concentration and birth weight

significantly correlated to maternal Homocysteine from preconceptional period to

pregnancy.

A mother with high serum Homocysteine levels at 8 weeks had 3 fold risk of

delivering low birth weight babies. Several other studies were done concerning the

association between maternal hyperhomocysteinemia with adverse maternal and

33

Serum homocysteine levels fall during pregnancy at around 8-10 weeks.

Homocysteine levels remains lower in the third trimester, less than that of the

preconceptional period. Lowest value is found in the second trimester (Andersson

et al., Kang et al).

Several mechanism have been proposed the reason of decreased homocysteine level in pregnancy,

Increased glomerular filtration rate

Increased plasma volume in pregnancy

Hemodilution

Increased transfer of B vitamins to the fetus

Hormonal effect on homocysteine during pregnancy

The exact mechanism is still not clear. Lower levels of Homocysteine acts as

a protection to the mother and fetus from the hyperhomocysteinemia associated

with pregnancy complications. Several studies were done which initiated and

addressed homocysteine as a biomarker which has predictive value in early

trimester at around 8- 10 weeks for identifying women who are at risk of

subsequently develop preeclampsia in the later trimester (Anna et al., Heitala et al

34

Hyperhomocysteinemia causes endothelial dysfunction which is one of the

major complications that is closely related to preeclampsia (Geseil et al., Herrmann

and Knapp et al., Stanger et al., 2001)(10)

In preeclampsia the homocysteine concentration is elevated throughout

pregnancy during all 3 trimesters and postpartum period. Women with previous h/o

preeclampsia also have elevated levels of serum homocysteine. The reason is still

unclear.

The other mechanisms proposed are:

Renal insufficiency(11)( a study done by Brattstrom L et all in 2003)

Decreased reformation of methionine from Homocysteine (Malinow et al in

1998)

Decrease in remethylation (Powers et al in 2004)

Disturbance in liver metabolism of Homocysteine

Reduced Vitamin B during preeclampsia

Folate was measured in only some studies. A study was conducted by

Powers et all, found that low levels of folate were found to have increased risk of

preeclampsia. Two ongoing studies on low Vitamin B12 and preeclampsia found

35

study conducted in Australian women by Kaiser et al demonstrated that MTHFR

mutation is not a risk factor for preeclampsia, if prenatal folate is substituted.

THE PATHOGENESIS OF PREECLAMPSIA:

It important to know the pathogenesis of preeclampsia which is similar to

that of elevated levels of homocysteine causing endothelial dysfunction.

In normal pregnancies, a subset of cytotrophoblasts called invasive

cytotrophoblasts migrate and invade the decidua tunica media of maternal spiral

arterioles and replace its endothelium with the subsequent destruction of the

medial, elastic, muscular and neural tissue. This process is known as pseudo

vascularization. By the end of the second trimester of pregnancy, the uterine spiral

arteries are lined exclusively by cytotrophoblast, and endothelial cells are no

longer present in the myometrial regions.

As a result of these changes, the maternal spiral arterioles undergo

transformation from small, muscular arterioles to large capacitance, low resistance

vessels. This allows increased blood flow to the maternal and fetal interface.

Remodelling of these arterioles begins in the first trimester and ends by 18-20

36

The early stage of pregnancy: Epithelial – endothelial transformation

During normal differentiation, invading cytotrophoblasts alter their adhesion

molecule expression from epithelial cells like integrins alpha 6/beta 1, alpha V/beta

5, & E-cadherin to those of endothelial cells like integrins alpha 1/beta 1, alpha V/

beta 3 and VE- cadherin.

FAILURE OF PSEUDOVASCULARISATION IN PREECLAMPSIA

Invasion of the decidual arterioles by cytotrophoblasts is incomplete and

limited to the proximal decidua. Shallow placentation is noted which leads to

reduction in uteroplacental perfusion.

This is due to a failure in the alteration in molecular expression necessary for

the differentiation of cytotrophoblasts required for pseudovascularization.

The up regulation of matrix metalloproteinase – 9 (MMP-9) and HLA-G

does not occur. Causes for the failure may be immunological and genetic factors.

Early hypoxic insult to the differentiating cytotrophoblast has also been

37 ABNORMAL PLACENTATION:

On the basis of the observation, that the only definitive cure for

preeclampsia is delivery of the placenta which plays a central role in the

pathogenesis, is supported by epidemiologic and experimental data.

Abnormal development of the placenta

Abnormal remodelling of spiral arteries

Defective trophoblastic differentiation

38 IMMUNOLOGICAL FACTORS

Dysregulation of maternal tolerance to paternally derived placental and fetal

antigens has been considered. This maternal-fetal immunomaladaptations is

characterized by defective co-operation between uterine natural killer (NK)cells

and fetal human leukocyte antigen (HLA) – C and the result is changes similar to

those seen in acute graft rejection.

Excessive production of immune cells causes secretion of tumour necrosis

factor alpha which causes apoptosis of the extravillous cytotrophoblasts. Women

with preeclampsia show decreased levels of HLA – G and HLA – E. The

endothelial cell dysfunction is due to an extreme activation of leukocytes in the

maternal circulation.

SYSTEMIC ENDOTHELIAL DYSFUNCTION

The circulating proangiogenic factors secreted by the placenta include

vascular endothelial growth factor (VEGF) and placental growth factor (PGF). The

antiangiogenic factors include soluble fms- like tyrosine kinase I receptor (sflt-1)

(otherwise known as soluble VEGF receptor type I).

Data show that an imbalance of proangiogenic and antiangiogenic factors

produced by the placenta may play a major role in mediating endothelial

39

Maynard et al observed that the serum levels of VEGF & PIGF were

decreased in women with preeclampsia. The receptor sFlt-1 is a receptor for

binding circulating VEGF and PIGF through its ligand binding region. Thus SFlt-1

has an antiangiogenic effect.

Excess production of s Flt – 1 is associated with an increased risk of

preeclampsia and early onset preeclampsia. Endoglin binds to circulating TGF-beta

and decreases the circulating levels. TGF-beta is a pro angiogenic molecule.

Risk factors include personal or family history of preeclampsia, primiparity,

new paternity, maternal age more than 40, higher BMI, Multiple pregnancy,

hyper-placentosis, interval between pregnancies either <2 years (or) >10 years, pre-

existing medical disorders like chronic kidney disease, chronic hypertension, and

homozygosity / heterozygosity.

Also, Kidney donors and women with sub clinical hypothyroidism and

antithyroid antibodies are at a higher risk of developing preeclampsia. It does not

40

CLASSIFICATION OF HYPERTENSION IN PREGNANCY

Chronic Hypertension: Hypertension present before pregnancy or before 20 weeks of gestation or which is diagnosed for the first time during

pregnancy and also does not resolve by 12 weeks postpartum.

Gestational Hypertension: Hypertension after 20 weeks of gestation.

Transient Hypertension: hypertension diagnosed after 20 weeks of pregnancy and resolves by 12 weeks postpartum.

Preeclampsia superimposed upon chronic hypertension occurs in a woman with

pre-existing hypertension.

PREECLAMPSIA CLASSIFICATION:

Mild preeclampsia is defined as the presence of hypertension (Systolic BP ≥ 140-159 and Diastolic BP ≥ 90 - 109 mm Hg) on 2 occasions, at least 6 hours apart, but

without any evidence of end-organ damage in a woman who was normotensive

before 20 weeks of gestation.

In a patient with pre existing essential hypertension, preeclampsia is

diagnosed if Systolic BP has increased by 30 mmHg or if Diastolic BP has

41

Severe preeclampsia is defined as if the BP is more than 160/110 on 2 occasions at least 6 hours apart in a pregnant woman who is on bed rest

Non severe SeverePE

Blood pressure >140/90 mmHg > 160/110 mmHg

Proteinuria >0.3 gm/24 hrs

Or dipstick > 1+

>5gms/ 24 hrs

Or dipstick > 3+

Serum creatinine normal Elevated

Pulmonary edema - +

Oliguria - +

IUGR - +

Headache - +

Visual disturbance - +

Epigastric pain - +

HELLP syndrome - +

Revisiting the role of First trimester as an Index of Maternal and Fetal

outcome was a study conducted by Mariano Mascarenhas et al. It was a cohort

study conducted between 18 to 12 weeks out comprising 100 antenatal women. In

this study serum homocysteine was significantly elevated in patients who had

previous history of PIH, IUGR, oligohydramnios and pregnancy loss. It was

42

A case control study was conducted in department of Obstetrics and

Gynaecology in in Ghaem hospitals, Iran in 2006 about Elevated plasma total

homocysteine in preeclampsia by Malihe Hasanzadehet al(15). The study group was

included from 28 to 40 weeks of gestation. It consists of 40 women in control

group, 37 women with mild pre eclampsia and 38 in severe preeclampsia.

Homocysteine was done in all patients. There was no difference between serum

homocysteine level in mild pre eclampsia and normal antenatal women but it was

significantly higher in severe preeclampsia patients.

A study conducted in Uttarakhand on “Hyperhomocysteinemia in pre

eclampsia: is routine screening rational?” By Sonia Miglaniet all from the

Department of Obstetrics and Gynaecology, Himalayan Institute Of Medical

Sciences in November 2015. It was also a case control study including 30

preeclamptic women and 30 normal women. p value was statistically significant

but mean value of serum homocysteine did not correlate with the severity of

preeclampsia. They concluded that maternal serum homocysteine level has a casual

role in pathogenesis of preeclampsia but to recommend it as a routine test, larger

studies were required.

A study on Hyperhomocysteinemiain preeclampsia was found to be

associated to higher risk pressure profiles by R.NOTO et all conducted in Italy at

43

weeks of pregnancy. Homocysteine levels in normal pregnancy was very low 5+/-

1.7 and significantly higher level was present in the PIH group which was

statistically significant. Serum homocysteine level was decreased in pregnant

women when compared to non pregnant women of the same gestational age. It is

proved that in the complex biochemical mechanism, high homocysteine levels is

due to lack of precursors like folate and B12. Genetic alteration is found in N5 N10

MTHFR enzyme associated with high levels of homocysteine as early as 15 weeks.

The results of the study shows that pregnant women developing preeclampsia

showed hyperhomocysteinemia already at 20- 24 weeks. Probably high levels of

homocysteine may be considered a marker for vascular damage and may lead to

Preeclampsia.

Homocysteine in pregnancies complicated by pre eclampsia with and

without IUGR; A comparison with normotensive pregnant women with isolated

IUGR and healthy pregnant women’. This study was conducted by Marzena

Laskowsha and et all. Chair and department of Obstetrics and Perintology,

Medical University of Lubin, Poland.

One of the common maternal conditions associated with IUGR is

maternal hypertension and especially the highest level of homocysteine is seen in

both the groups complicated by preeclampsia with or without IUGR.

44

causes alteration in the coagulation system and enhances platelet activation.

Hyperhomocysteinemia is also present in normotensive pregnant patient with

IUGR.

Vitamin B6, B12, and folate play central role in metabolism of

homocysteine. If there is no B vitamins in adequate amount for the metablolic

changes there is natural decrease of homocysteine may not occur and causes

hyperhomocystenemia.

Hyperhomocystenemia due to MTHFR mutation can cause

hyperhomocystenemia which can be corrected by administration of folate. A study

conducted by Markedos et al, showed that maternal levels of vitamin B12 and folic

acid are not significantly different in preeclampsia patients who have

hyperhomocystenemia when compared to normal antenatal patients . So

hyperhomocystenemia in pregnancy might not always be due to B vitamin or folic

acid deficiency. In this study, all women were supplemented with B vitamins and

folic acid.

On contrary several studies says that homocysteine levels were significantly

elevated in severe preeclampsia when compared to mild preeclampsia.

Mao et al observed elevated serum homocysteine levels in patients with

45

levels and asymmetric dimetylarginine (ADMA). They concluded that the

homocysteine - ADMA-NO pathway may be reason for the pathogenesis in

preeclampsia and may be used as a marker to assess the severity of the disease.

Lopez – Quesada et al, also concluded that the homocysteine level was

significantly higher in preeclampsia. Similar study was conducted by Wang et all

and concluded the same.

A study was conducted by Shilpa A.V et al about changes in the

homocysteine levels in normal pregnancy and preeclampsia and its relation to

oxidative stress. They studied hyperhomocysteinemia causing oxidative damage by

release of Malondialdehyde (MDA), which is a metabolite in lipid peroxidation

found to be elevated in hyperhomocyteinemia. The mean value of MDA

352.13±52.54 which was statistically significant P value was <0.001 in

preeclampsia when compared to normal pregnancy where mean value of MDA

208.67±43.54. This may be due to reaction between the maternal dyslipidemia and

diseased placenta causing oxidative damage in the pathogenesis of preeclampsia.

The mean homocysteine value also was significant in preeclampsia group, P

value < 0.001. They concluded that B vitamin supplementations, folic acid, nitric

46

stress and restores the endothelial damage. Similar study was also reported by

Uzen et al and concluded the same.

In this study homocysteine was elevated in the preclampsia group but

statistically was not significant to support the fact to use it as a predictor test which

was supported by Laxmi Maru et al., who studied that homocysteine can be used as

a predictive marker for PIH and it was compared with the normotensive patient

along with the complications. A higher level of homocysteine was associated with

many maternal complications like abruptio placenta, retinopathy, eclampsia,

MODS. Homocysteine to be used as a predictor is under study. More large scale

studies are need.

TREATMENT OF HYPERHOMOCYSTENEMIA:

Elevated homocysteine levels is associated with number diseases which was

already explained. In case of homocystienuria methionine restriction diet is given,

which produces cysteine from methionine through homocysteine, after which

cysteine becomes the essential amino acid.

In patients with Cystathionine beta synthase (CBS) deficiency, which is

heterogeneous disease, vitamin B 6 is supplemented, which improves the function

47

patients this treatment may not respond, in that case folic acid and vitamin B12 is

supplemented to induce MS activity which reduces the serum homocysteine level.

In patients who don’t respond to vitamin B6 have higher mortality rate in

their early years. A study of homocystinuria was conducted, which showed that

patients before 30 years, 23% did not respond to vitamin B6 and only 4 %

responded to vitamin B6, 50% of the untreated cases were expected to have

thromboembolic events. Non responsive cases showed higher rate of mental

retardation and low IQ when compared with the responsive group when treated

early.

Mammals cannot produce folate, therefore folate is an essential nutrient,

which is available in fruits and vegetables, especially green leafy vegetables.

Improved diet and vitamin supplementation can reduce the homocysteine levels by

activating the remethylation pathway.

Additional supplementation of 1 mg of vitamin B12 reduces the unopposed

folic acid administration in patients with vitamin B12 deficiency and also in

patients with intrinsic factor deficiency and malabsorption status.

A study was conducted by Esraa et al, about treatment of

hyperhomocysteinemia and pregnancy outcome. In this study the patients with

48

patients with recurrent pregnancy loss in around 18-20 weeks of gestation, these

patients were treated with folic acid 5mg and vitamin B12 40 mg daily and was

followed throughout pregnancy. There was significant lowering of homocysteine

levels after treatment P value was < 0.0001 and better improvement in outcomes.

MTHFR gene mutation or folate deficiency is associated with major 3rd

trimester complications like preeclampsia, recurrent pregnancy loss, abruptio

placenta and IUGR. Due involvement of hyperhomocysteinemia in the production

of thrombotic events anticoagulant treatment is also recommend throughout

pregnancy. In case of unfractionated heparin patients PT INR/APTT levels are

monitored.

CURRENT POSITION:

Although it is proved that folate, Vitamin B supplementation decreases the

homocysteine levels, the true effect on reducing the disease remains to be

determined.

From the above studies it is understood that treatment will at least stop the

progression of the disease and to some extent it is possible to reverse the damage

of the disease that has been already done by regeneration of the tissues and

49

Lowering homocysteine levels improves cardiovascular function and

restenosis following vessel stenosis.

Folic acid supplementation during pregnancy found that there is a decrease

in the neural tube defects but prevention of preeclampsia is not clearly explained,

need more further large group of studies.

Hyperhomocysteinemia is a risk factor for several diseases. Homocysteine

level is influenced by several factors either acquired and also lifestyle factors.

Treatment in reducing homocysteine levels is cheap and safe. Therefore it is

important to continue studies this field so that we may be able to establish the

mechanisms by which hyperhomocystenemia causes disease and the potential

50

MATERIALS AND METHODS

The study was conducted in the department of Obstetrics and Gynaecology

at PSG Institute Medical Sciences and Research from June 2016 to June 2017.

The study period was 12 months.

STUDY DESIGN

Prospective observational study

STUDY POPULATION

Patients were selected between 28- 40 weeks. Total study group included 60

subjects out of which 30 patients were admitted in labour ward with preeclampsia

was chosen as cases and 30 patients was chosen as controls who was admitted for

safe confinement towards term in labour ward. Sample was collected

simultaneously in both cases and controls.

INCLUSION CRITERIA

Antenatal women, either primigravida or multigravida with 28 - 40 weeks of

gestational age.

CASES: 30 women with preeclampsia

51

Cases were selected as and when they presented. Preeclampsia was

diagnosed if BP > 140/90 mmHg on 2 occasions measuring 6 hours apart in sitting

or semi recumbent position associated with proteinuria 300 mg or more in 24 hours

urine sample or more than 1+ in dipstick in random urine samples.

With detailed history taking and routine antenatal investigations along with

PIH investigations like BT, CT, APTT, PT, INR, fibrinogen, urine albumin, urine

PCR and uric acid. Severity of preeclampsia was diagnosed depending upon the

BP reading > 160/110 mmHg and the presence of proteinuria more than 5 gms

with imminent symptoms. Serum homocysteine was done in all patients.

EXCLUSION CRITERIA:

Chronic hypertension

Diabetes mellitus

APLA syndrome

Preterm labour

Twins

Smokers

52 METHODOLOGY

5 ml of venous blood is drawn from the antecubital vein , in cases along with

other PIH investigations and in controls , when the blood was drawn for

other routine antenatal investigations.

Collected in the EDTA tube

Send to biochemistry Lab within 30 minutes

53

RESULTS AND ANALYSIS

TABLE-1:

AGE DISTRIBUTION

AGE CASES CONTROLS

< 20 2(6.6%) 0

21- 25 11(36.6%) 10 (10.33%)

25- 30 11(36.6%) 19(63.3%)

>30 6(20%) 1 (3.3%)

In my study, total number patients were 60 out of which 30 patients were

controls and 30 patients were cases.

In cases, 2 patients were less than 20 years, 11 patients between 21 to 25

years, 11 patients between 25-30 years and 6 patients above 30 years.

In controls, 10 patients between 21-25 years, 19 patients between 25-30

54 TABLE-2:

THE MEAN AGE DISTRIBUTION OF THE STUDY

S NO N Mean SD

1 CASES 30 25.90 5.274

2 CONTROLS 30 24.90 2.480

The mean Age distribution in cases is 25.90±5.274, which is similar to that

55 TABLE-3:

OBSTETRIC SCORE:

SNO PRIMI MULTI

1 CASES 23 7

76.7% 23.3%

2 CONTROLS 25 5

83.3% 16.7%

In cases 23(76.7%) are primi and 7(23.3%) multi. In controls 25(83.3%) are

56 TABLE-4:

GESTATIONAL AGE:

GESTATIONAL AGE CASES CONTROLS

29- 33.6 14 (46%) 3 (10%)

34-37 9 (30%) 7 (23.3%)

>37 7 (23.3%) 20 (66.6%)

TOTAL 30 30

In 30 cases, 14 patients were between 29-34 weeks, 9 patients between

34-37 weeks, 7 patients were more 34-37 weeks. In controls, 3 patients between 29-34

57 TABLE-5:

THE MEAN GESTATIONAL AGE:

SNO N Mean SD

1 CASES 30 34.80 2.398

2 CONTROLS 30 37.33 1.493

The Mean Gestational Age in cases are 34±2.398 and the mean gestational

Age of the controls are 37.33±1.493.The mean gestational was more in controls

when compared to cases, this is because all the preeclamptic patients were

58 TABLE-6:

BMI

BMI CASES CONTROLS

18-24.9 0 5( 16.6%)

25-29.9 9( 30%) 10( 33.3%)

>30 21(70%) 15( 50%)

>35 0% 0%

TOTAL 30 30

From the above table out of 30 cases, 21 patients ( 70%) comes under class I

obesity when compared to controls it was only 50%. No patients were found to

59 TABLE-7:

THE MEAN BMI

N Mean SD P value

CASES 30 30.333 2.2489

.002

CONTROLS 30 28.517 2.0615

BMI of both the cases and controls were noted and mean was calculated .

The mean of BMI in cases was 30.333±2.2489 when compared to controls the

mean value was 28.517±2.06 which was statistically significant . P value was <

60 TABLE-8:

HOMOCYSTEINE LEVELS

Homocysteine levels CASES CONTROLS

< 5µmol/L 4 ( 13.3%) 9( 30%)

5-7µmol/L 4(13.3%) 13( 43.3%)

7-12µmol/L 12( 40%) 7( 23.3%)

>12µmol/L 10( 31.3%) 1(3.3%)

TOTAL 30 30

The normal value of homocysteine is 5-7µmol/L, 4( 13.3%) patients in

cases and 9( 30%) patients in controls had low values that is below 5µmol/L. 4

(13.3%)patients in cases and 13 ( 43.3%)patients in controls had normal value of

homocysteine. 12( 40%) patients in cases and 7( 23.3%)patients in controls had

mild elevation of homocysteine. In my study 10( 31.3%) patients in cases and

61

62 TABLE-9:

MEAN HOMOCYSTEINE LEVELS IN CASES AND CONTROLS

SNO N Mean SD P value

1 CASES 30 9.989 4.1624

0.000

2 CONTROLS 30 6.038 2.0390

This table shows the association of serum homocysteine levels in cases and

controls . The mean homocysteine value in case is 9.989±4.1 and the mean

homocysteine level in control is 6.038±2.03 , which found to be statistically

63 TABLE-10:

ASSOCIATION OF HOMOCYSTEINE IN NORMOTENSIVES AND IN WOMEN WITH PREECLAMPSIA:

Normal Increased

homocysteine level

Less than normal homocysteine

CONTROLS 19(63.33%) 4(13.333%) 7(23.33%)

CASES 6(20%) 24(80%) 0

The above table shows that homocysteine value is unchanged in 63.3% of

the normotensive patients and is decreased less than normal range in 23.33% when

compared to homocysteine levels in preeclampsia patients were 80% of patients

64 TABLE-11:

ASSOCIATION OF HOMOCYSTEINE LEVELS WITH MILD PREECLAMPSIA AND SEVERE PREECLAMPSIA

Normal homocysteine

Increase homocysteine

Total

Non severe preeclampsia 8(61%) 5(38%) 13

Severe preeclampsia 5(29.4%) 12( 70.5%) 17

From the above table it is found that increased homocysteine levels was

found in severe preeclampsia 12(70% )patients when compared to mild

preeclampsia which was only 5(38%) patients. More number of patients are

65

TABLE-12:

HEMOGLOBIN

HEMOGLOBIN CASES CONTROLS

<8G/DL 3 (10%) 0%

8.1-9.5 G/DL 5(16.6%) 0%

9.6-10.5 G/DL 6(20%) 16(53.33%)

>10.5 G/DL 16(53.3%) 14(46.6%)

TOTAL 30 30

In cases, 3 patients had severe anemia, 5 patients had moderate anemia, 6

patients with mild anemia, more than 16 patients had normal HB levels. In

66

TABLE-13:

THE MEAN HB VALUE FOR CASES AND CONTROLS

N MEAN SD P VALUE

CONTROLS 30 10.800 2.1148

.924

CASES 30 10.840 0.8830

The mean value of HB was done in both cases and controls. It was found

that the mean HB value of cases 10.800±2.11 and the mean HB value of controls

67 TABLE-14:

ASSOCIATION OF HOMOCYSTEINE LEVELS WITH IUGR

Homocysteine With IUGR Without IUGR P value

Normal 2 (25%) 6 (75%)

0.614

Mild elevation 2(15.4%) 11(84.6%)

Moderate elevation 6(66.7%) 3( 33.3%)

Raised homocysteine value showed higher incidence of IUGR 6 ( 66.6%)

when compared to low level of homocysteine 2 (15.4%) but it is not statistically