Maternal serum activin A is not elevated before preeclampsia

in women who are at high risk

Catherine A. Blackburn, MBChB,a Jeffrey A. Keelan, PhD,b Rennae S. Taylor, BScN, MHSc,a and
Robyn A. North, MBChB,a PhD
Auckland, New Zealand
OBJECTIVE: The purpose of this study was to determine whether, in women who are at high risk of the development of preeclampsia, serum activin A concentrations are elevated before the disease and whether activin A is a useful predictor of preeclampsia.
STUDY DESIGN: Sera were collected on five occasions throughout pregnancy from women with chronic hypertension, renal disease, or previous early-onset preeclampsia (n = 80 women). Women were classified as
control subjects (normotensive or stable chronic hypertension), gestational hypertensive, or preeclamptic (de
novo or superimposed). Serum activin A concentrations were measured by immunoassay. Differences in activin A concentrations between groups were analyzed with the use of a mixed-models procedure; screening
test characteristics were calculated.
RESULTS: Twenty-six women (33%) had gestational hypertension, and 17 women (21%) had preeclampsia
or superimposed preeclampsia. Serum activin A levels increased with gestation in all groups (P = .0001), but
there were no significant difference in activin A levels between groups (P = .75).
CONCLUSION: In women who were at high risk of the development of preeclampsia, serum activin A levels
are not elevated with preeclampsia. Activin A is not a useful predictor of preeclampsia in this setting. (Am J
Obstet Gynecol 2003;188:807-11.)

Key words: Activin A, pregnancy, preeclampsia, prediction

Activin A is a homodimeric glycoprotein hormone that

belongs to the transforming growth factor super family.
Activin A is produced by many tissues, which include the
ovary, placenta, decidua, and fetal membranes. Its biologic functions are diverse and, in pregnancy, include the
regulation of trophoblast differentiation and placental
steroidogenesis and prostaglandin production.1
In normal pregnancy, circulating activin A concentrations have been found to increase throughout gestation,
peaking in the third trimester.2,3 The placenta has been
postulated to be the principal source of activin A that is
detected in the circulation during pregnancy. Serum activin A levels have also been found to be elevated
markedly in women with preeclampsia, particularly those

From the Department of Obstetrics and Gynaecologya and Liggins Institute and Department of Pharmacology and Clinical Pharmacology,b
University of Auckland Faculty of Medical and Health Sciences.
Supported by Auckland Medical Research Foundation, Health Research
Council of New Zealand.
Received for publication July 19,2002; revised November 4, 2002; accepted November 15, 2002.
Reprint requests: Robyn A North, MBChB, PhD, Department of Obstetrics and Gynaecology, University of Auckland, Private Bag 92019,
Auckland 1001, New Zealand. E-mail: r.north@auckland.ac.nz
2003, Mosby, Inc. All rights reserved.
0002-9378/2003 $30.00 + 0
doi:10.1067/mob.2003.173

women with early onset disease.4-7 Because activin A is increased before 20 weeks in women who later have preeclampsia, it has been investigated as a predictive marker
of preeclampsia.3,7-9 In a low-risk population, Muttukrishna et al3 reported that serum activin A concentrations
at 15 to 19 weeks could discriminate preeclampsia with a
sensitivity of 41%, a specificity of 89%, and a likelihood
ratio of 3.8, which gives a posttest probability of preeclampsia of 16%. At 21 to 25 weeks, the sensitivity was
59%, and the specificity was 87%. Similar sensitivity
(60%) and specificity (90%) for activin A to predict preeclampsia in women who were at a low risk was reported
by Silver and Canick.9 Activin A appears to be more predictive of early onset preeclampsia, by detecting almost
90% of these women at 21 to 25 weeks of gestation, with a
likelihood ratio of 11.4.3
To date, there have been no comparable studies in
women who were at a high risk of the development
of preeclampsia, such as those women with previous preeclampsia (14%-20% risk),10,11 chronic hypertension
(12%-45% risk),12,13 and renal disease (24%-54%
risk).14,15 The aim of the present study was to determine,
in women at high risk of the development of preeclampsia, whether serum activin A is altered before the onset of
clinical disease and is a clinically useful predictor of preeclampsia.
807

808 Blackburn et al

March 2003
Am J Obstet Gynecol

Figure. Total serum activin A concentrations (milli-international units per liter) were assayed in control subjects, women
with gestational hypertension, and women with preeclampsia. Median and interquartile ranges are shown. No significant
differences were found between control subjects and two hypertensive groups (mixed-models procedure of SAS; SAS Institute Inc, Cary, NC).

Material and methods

A cohort of women who were at high risk of the development of preeclampsia was followed up between June
1993 and May 1995. Women were included if they had essential hypertension, renal disease, or previous earlyonset preeclampsia and were delivered by 32 weeks of
gestation. Essential hypertension was defined as systolic
blood pressure if 140 mm Hg or diastolic blood pressure
of 90 mm Hg before 20 weeks of gestation or known essential hypertension receiving antihypertensive medications before pregnancy. Exclusion criteria were women at
>18 weeks of gestation at the first visit, multiple pregnancy, and congenital malformations. Serial serum samples were obtained at 8 to 13 weeks, 15 to 19 weeks, 21 to
25 weeks, 27 to 31 weeks, and 34 to 38 weeks of gestation
and were stored at 80C until assayed. Gestation was calculated from the date of the last menstrual period or, if
there was a discrepancy in gestation of more than 5 days
between the last menstrual period and an ultrasound
scan that was performed before 20 weeks, then gestation
was calculated from the scan. The Regional Health Authority ethics committee approved the study; informed
consent was obtained from all women.
The end points were gestational hypertension and preeclampsia. Gestational hypertension was defined, in normotensive women, as a systolic blood pressure of 140
mm Hg or a diastolic blood pressure of 90 mm Hg after
20 weeks of gestation or, in women with chronic hypertension, as a rise in systolic blood pressure of 30 mm Hg
or diastolic blood pressure of 15 mm Hg. Preeclampsia
was defined as the development of gestational hypertension with de novo proteinuria of 2+ protein on dipstick

or >0.3 g/24 hours or, if preexisting proteinuria was

found, a doubling of 24-hour urine protein excretion.
Two separate investigators (C. B., R. N.) classified the
women into clinical groups according to pregnancy outcomes and were concordant in their classification in 94%.
Small-for-gestational-age infants were classified as birth
weight <10th percentile, as defined by sex-adjusted
data.16
Total serum activin A was measured by enzyme-linked
immunosorbent assay, as previously described.7,17 The
assay was calibrated against the National Institute for Biological Standards and Control activin A standard 91/626,
where 1 IU is equivalent to 1 g of recombinant human
activin A (National Institute for Biological Standards and
Controls, Potters Bar, UK). Serial samples from each
woman were included on the same enzyme-linked immunosorbent assay plate, with each plate containing a
representative mix of samples from each patient group.
One investigator (R. S. T.) determined the enzyme-linked
immunosorbent assay plate layout, and the assays were
performed blinded to pregnancy outcome. The number
of serum samples that were available for assay for 8 to 13
weeks, 15 to 19 weeks, 21 to 25 weeks, 27 to 31 weeks, and
34 to 38 weeks gestation, respectively, were as follows:
control subjects (n = 18, 37, 32, 34, 29), women with gestational hypertension (n = 25, 25, 26, 24, 21), and women
with preeclampsia (n = 9, 17, 17, 17, 13). Samples were diluted >1:3 to bring them within the optimal region of the
calibration curve. Intra-assay and interassay coefficients
of variation were 2.9% and 14.1%, respectively.
Clinical data was analyzed with the 2, Fisher exact, or
analysis of variance and post hoc Tukey tests. The longi-

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Table I. Maternal characteristics according to hypertensive complications in pregnancy

Age (y)*
Ethnicity (%)
European
Asian
Polynesian
Nulliparous (%)
Early pregnancy <20 wk
Systolic blood pressure (mm Hg)*
Diastolic blood pressure (mm Hg)*
Proteinuria 2+ or >0.3 g/24 h (%)
Creatinine level >0.10 mmol/L (%)
Urate (mmol/L)*
End of pregnancy
Systolic blood pressure (mm Hg)*
Diastolic blood pressure (mm Hg)*
Proteinuria 2+ or >0.3 g/24 h (%)
Creatinine level >0.10 mmol/L (%)
Urate (mmol/L)*

Control subjects
(n = 37)

Gestational
hypertension (n = 26)

Preeclampsia
(n = 17)

P value

30.3 5.7

30.4 5.3

32.2 6.5

.51

60
8
32
51

77
0
23
42

71
6
23
41

.51
.73

137 18
90 12
20
11 (n = 27)
0.24 0.08 (n = 24)

141 20
87 12
12
5 (n = 21)
0.25 0.07 (n = 20)

142 17
91 12
18
27 (n = 15)
0.31 0.11 (n = 15)

.57
.58
.83
.14
.02

133 12
90 9
16
9 (n = 33)
0.32 0.07 (n = 31)

158 14
104 8
12
9 (n = 22)
0.36 0.09 (n = 25)

170 26
108 10
100
18
0.43 0.11

.0001
.0001
.0001
.63
.0004

Statistical analysis was by analysis of variance, 2, and Fisher exact test (group comparisons).
*Data are given as mean SD.
Post hoc Tukey analysis: preeclampsia versus control, P = .0001; gestational hypertension versus control, P = .0001.
Stable chronic proteinuria.
Post hoc Tukey analysis: preeclampsia versus control, P = .001.

tudinal activin A data were analyzed with a mixed-models

procedure of SAS (SAS Institute Inc). This method offered an efficient approach to repeated measures of
serum activin A and permitted maximum likelihood imputation of missing data. Screening test characteristics
were analyzed using a diagnostic and agreement statistics spreadsheet.18 A probability value of <.05 was considered significant.
Results
From the 87 women who were recruited initially, 7
women were excluded from the final analysis for the following reasons: withdrawal from the study (n = 2
women), early pregnancy loss (n = 3 women), fetal malformation diagnosed at term (n = 1 woman), and a second pregnancy in a woman already included in the
study (n = 1 woman). Of the 80 women who were included in this study, 57 women (71%) had essential hypertension; 21 women (26%) had renal disease
(glomerulonephritis [n = 9 women], reflux nephropathy [n = 8 women], renal scleroderma [n = 1 woman],
renal transplantation [n = 3 women]); and 2 women
(3%) had previous early-onset preeclampsia alone.
Early-onset preeclampsia had complicated previous
pregnancies in 6 of the women who were classified with
chronic hypertension or renal disease.
Preeclampsia complicated 17 pregnancies (21%); 26
women (33%) had gestational hypertension and 37
women (46%) remained normotensive or had stable
chronic hypertension (control subjects). Maternal characteristics of these three groups in early and late preg-

nancy are shown in Table I. Proteinuria in control subjects and women with gestational hypertension reflects
their underlying renal disease and remained stable in
pregnancy. In 3 women in the control group, proteinuria
improved in pregnancy; in 2 control subjects, proteinuria
worsened, but the women did not meet other criteria for
preeclampsia. Women with preeclampsia were delivered
earlier than control subjects; their babies had lower birth
weights, and almost one third of the babies were small for
gestational age (Table II).
Serum activin A concentrations are shown in the Figure. Activin A levels in all three groups increased significantly throughout gestation (P < .0001). There was no
difference among the three groups in the concentration of activin A that was measured longitudinally
throughout pregnancy (P = .75). As a screening test for
the prediction of the development of preeclampsia
using the 90th percentile activin A level at 21 to 25
weeks in control subjects as a cutoff value (4.34
mIU/L), the sensitivity was 18% (95% CI, 4-43), the
specificity was 88% (95% CI, 71-96), the likelihood
ratio was 1.41 (95% CI, 0.4-5.6), and posttest probability was 43% (95% CI, 10-82).
Comment
This is the first report to investigate serum activin A
concentrations throughout pregnancy in women at high
risk of the development of preeclampsia. Although maternal serum activin A concentrations increased with advancing gestation, as previously reported,2,3 we found no
significant difference in activin A levels in women who

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Table II. Fetal characteristics according to hypertensive complications in pregnancy

Gestational age at delivery (wk)*

Preterm delivery (%)
<32 wk
33-36 wk
37 wk
Birth weight (g)*
Small for gestational age (%)
5th-<10th percentile
<5th percentile

Control subjects
(n = 37)

Gestational hypertension
(n = 26)

Preeclampsia
(n = 17)

P value

38.7 1.9

37.8 2.7

35.5 3.3

.0002

0
16
84
3279 491

4
19
77
2996 836

24
35
41
2363 790

.005
.0001

0
3

15
16

18
12

.009

Statistical analysis by analysis of variance, 2, or Fisher exact test (group comparisons).

*Data are given as mean SD.
Post hoc Tukey analysis: preeclampsia versus control, P = .001.
Post hoc Tukey analysis: preeclampsia versus control, P = .0001

had preeclampsia compared with those women who remained normotensive. At 35 to 38 weeks of gestation, a
trend toward higher activin A levels in the preeclamptic
group was seen, but this did not reach statistical significance. Before 25 weeks of gestation, maternal serum activin A concentrations were very similar in women who
were destined to have preeclampsia and those women
whose condition remained normotensive or who had stable chronic hypertension. Consequently, activin A performed poorly as a screening test when it was evaluated at
21 to 25 weeks of gestation, with a sensitivity of only 18%
and a specificity of 86%. This is in marked contrast to the
findings in women who are at low risk in whom activin A
is significantly elevated before the onset of preeclampsia.3,7,8 This study was not designed to investigate women
with preeclampsia at the time of clinical disease, and we
cannot exclude the possibility of elevated activin A levels
once the disease is manifest.
There may be several reasons for the similar activin A
levels in high-risk women who remained healthy and
those women who had preeclampsia. The diagnosis of
preeclampsia is always difficult in the presence of underlying renal disease, and it is possible the women who are
classified as having preeclampsia may not have had the
disorder. We attempted to minimize this possibility by
using stringent clinical criteria to classify the groups; the
characteristics of the women with preeclampsia and gestational hypertension support the validity of our classifications. Women with preeclampsia had significantly
higher blood pressure, proteinuria, and serum urate levels compared with the control subjects. In addition, they
were delivered at an earlier gestation, with one quarter of
the babies were delivered by 32 weeks of gestation, and
one third of the babies were small for gestational age.
An alternative explanation for the similar activin A levels in the different groups could lie in the influence of abnormal renal function in some women, which could
modify the renal excretion of activin A.19 Abnormal renal

function is unlikely to be the explanation as there were

only 8 women in the study with an elevated serum creatinine level (>0.10 mmol/L) early in pregnancy. These
women were distributed evenly across the groups, and
their serum creatinine levels generally remained stable,
with only one woman in each group showing deterioration in creatinine level at the end of pregnancy. In addition, the median activin A level for women with abnormal
renal function was not different from the median levels in
all three groups. Moreover, the median activin A concentrations in our control group were similar to the values
that were measured in normal women that were reported
in a recent study performed in our laboratory.7
A final possible explanation for our findings is that the
pathogenic mechanisms that contribute to the manifestation of preeclampsia in women with chronic hypertension and renal disease differ from those that occur in
healthy women who have the disease. The cellular origin of the increase in activin A in healthy women who
have preeclampsia has yet to be ascertained, although
there is preliminary evidence that placental activin A expression in preeclampsia is elevated, which suggests that
placental production is at least a contributory source.20
Proinflammatory cytokines that are involved in the pathogenesis of preeclampsia, including interleukin-1 and
tumor necrosis factor-, have been found to stimulate
placental activin A secretion.21 Furthermore, activin receptors are present in the endothelium of placental vasculature,20 so increased activin levels in preeclampsia
may also represent or contribute to endothelial dysfunction. Preeclampsia is a clinical disorder that is a crude
manifestation of diverse pathologic features. The failure
to demonstrate increased activin A concentrations before
the development of preeclampsia in this cohort of
women with predominantly chronic hypertension and
renal disease may be indicative of different pathophysiologic mechanisms that contributed to preeclampsia in
this setting.

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In conclusion, we report that serum activin A is not predictive for the development of subsequent preeclampsia
in a cohort of women at high-risk of the development of
the disease. The search for predictive markers in this
group remains a worthwhile objective but should focus
on other biochemical markers.
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