Maternal First-Trimester Alpha-Fetoprotein and Placenta-Mediated Pregnancy Complications

Abstract

BACKGROUND: Maternal serum markers used for trisomy 21 screening are associated with placenta-mediated complications. Recently, there has been a transition from the traditional first-trimester screening (FTS) that included PAPP-A (pregnancy-associated plasma protein-A) and beta-hCG (human chorionic gonadotropin), to the enhanced FTS test, which added first-trimester AFP (alpha-fetoprotein) and PlGF (placental growth factor). However, whether elevated first-trimester AFP has a similar association with placenta-mediated complications to that observed for elevated second-trimester AFP remains unclear. Our objective was to estimate the association of first-trimester AFP with placenta-mediated complications and compare it with the corresponding associations of second-trimester AFP and other first-trimester serum markers. METHODS: Retrospective population-based cohort study of women who underwent trisomy 21 screening in Ontario, Canada (2013–2019). The association of first-trimester AFP with placenta-mediated complications was estimated and compared with that of the traditional serum markers. The primary outcome was a composite of stillbirth or preterm placental complications (preeclampsia, birthweight less than third centile, or placental abruption). RESULTS: A total of 244 990 and 96 167 women underwent FTS and enhanced FTS test screening, respectively. All markers were associated with the primary outcome, but the association for elevated first-trimester AFP (adjusted relative risk [aRR], 1.57 [95% CI, 1.37–1.81]) was weaker than that observed for low PAPP-A (aRR, 2.48 [95% CI, 2.2–2.8]), low PlGF (aRR, 2.28 [95% CI, 1.97–2.64]), and elevated second-trimester AFP (aRR, 1.97 [95% CI, 1.81–2.15]). When the models were adjusted for all 4 enhanced FTS test markers, elevated first-trimester AFP was no longer associated with the primary outcome (aRR, 0.77 [95% CI, 0.58–1.02]). CONCLUSIONS: Unlike second-trimester AFP, elevated first-trimester AFP is not an independent risk factor for placenta-mediated complications.

Fetal and Placental Causes of Elevated Serum Alpha-Fetoprotein Levels in Pregnant Women

“…While there is no doubt about the utility of AFP results from second-trimester studies in this regard, the usefulness of first-trimester results raises doubts. According to studies by Hu et al and Melamed et al, elevated AFP values in the first trimester of pregnancy are not useful as standalone diagnostic markers for adverse pregnancy outcomes (APOs) and should not lead to excessive obstetric surveillance [66,67].…”