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Association of kisspeptin-10 levels with

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Arch Gynecol Obstet (2012) 285:649653
DOI 10.1007/s00404-011-2061-0
MATERNAL-FETAL MEDICINE
Association of kisspeptin-10 levels with abortus imminens:
a preliminary study
Serif Kavvasoglu Zehra Sema Ozkan
Banu Kumbak Mehmet Smsek Necip Ilhan
Received: 12 May 2011 / Accepted: 2 August 2011 / Published online: 17 August 2011
Springer-Verlag 2011
Abstract
Purpose To investigate the association between kisspep-
tin 10 (Kp-10) levels and early pregnancy bleeding and
perinatal outcome.
Methods A total of 20 pregnant women with the com-
plaint of vaginal bleeding during 718 gestational weeks
and 20 healthy gestational week matched pregnant women
were included in the study. Maternal plasma Kp-10 levels
were measured with the enzyme immunoassay method.
Adverse pregnancy outcomes like intrauterine growth
restriction, preterm delivery, preeclampsia and low birth
weight were evaluated in both groups.
Results Maternal plasma Kp-10 levels (p = 0.01) and
birth weight (p = 0.06) were found to be lower in women
with bleeding. Intrauterine growth restriction, preterm
delivery and intrauterine exitus were noted more commonly
in women with bleeding (10 vs. 0%, 25 vs. 15% and 20 vs.
0%, p = 0.08). Preeclampsia were developed in 5% of both
groups. Kp-10 levels showed positive correlation with
gestational week (p = 0.02) and ALT levels (p = 0.02).
Conlusion Kp-10 levels were found lower in women with
early pregnancy bleeding.
Keywords Early pregnancy bleeding
Kisspeptin-10

Pregnancy outcome
Trophoblast invasion
S. Kavvasoglu
Z. S. Ozkan (&)
B. Kumbak
M. Smsek
Department of Obstetric and Gynecology, Firat Universitesi
Hastanesi Kadin Dogum Anabilim Dali, 23119 Elazig, Turkey
e-mail: zehrasema@yahoo.com
N. Ilhan
Department of Biochemistry, Firat University School
of Medicine, Elazig, Turkey
Introduction
Trophoblast invasion strongly resembles tumor metastasis
in that trophoblasts drive the same molecular mechanisms
for their migration and invasion as tumor cells [1, 2].
Degredation of extracellular matrix (ECM) by matrix-
metalloproteinases (MMPs) is the most important part of
this process [2]. Tight regulation of this physiologic
invasion process in temporal and spatial manner differ-
entiates it from tumor metastasis. Temporal control
allows a peak of trophoblast penetration into the maternal
uterus at around week 12 of gestation that declines rap-
idly thereafter. Spatial control restricts the depth of tro-
phoblast invasion to the decidua and the proximal third of
the myometrium [3]. Dysregulation of this perfectly
controlled process of trophoblast invasion results in a
wide spectrum of pregnancy complications [4, 5]. TGF-b,
TNF-a, and gonadotropin releasing hormone inhibit tro-
phoblast invasion [68] and recently, kisspeptins have
also been identified as additional regulators of trophoblast
invasion [9].
Kisspeptins (Kp-54, Kp-14, Kp-13 and Kp-10) comprise
a family of peptides derived from the primary translation
product of the KiSS-1 gene. They are the endogenous
ligands of KiSS-1 receptor (KiSS-1R) and Kp-10 has the
highest affinity for KiSS-1R [10]. Kisspeptins are pre-
dominantly secreted from syncytiotrophoblasts and their
expression level is the highest in the first trimester [11].
Only Kp-10 stimulates intracellular Ca2? release in tro-
phoblasts of the early placenta [9] and regulates invasion of
the trophoblast into the decidua by inhibiting MMP
expression [1214]. Abortus imminens is one of the fre-
quently seen complications of early gestation. We hypot-
esized that abortus imminens could be the result of
ineffective placentation and we intended to investigate the
123
650
possible association between serum Kp-10 levels and early
pregnancy bleeding.
Materials and methods
Study population
A group of 40 women with singleton pregnancies who
received perinatal care from Firat University Hospital,
Department of Obstetric and Gynecology during November
2009June 2010 were included in the present study.
Twenty of them were hospitalized with the diagnosis of
abortus imminens (study group) and the remaining 20
healthy pregnant women were included as the control
group. The gestational ages of all the pregnant women
were between 7 and 18 weeks. A detailed medical history
of subjects was obtained through administration of health
questionnaires. Body mass index (BMI) of women was
estimated. The women who had retroplacental hematoma,
multiple pregnancy, history of trauma, history of pre-
eclampsia in previous pregnancy, excessive daily smoking
and alcohol drinking, fetal anomaly, maternal or fetal
infection, systemic lupus erythematosus, diabetes mellitus,
hypertension, chronic renal failure, hematologic diseases,
uterine anomaly, cervical polyp, gynecologic malignancy,
gestational trophoblastic disease,and ectopic pregnancy
were excluded from the study. Written informed consent
was obtained from all the women.
Blood sampling
Maternal blood samples were drawn in the morning using a
polypropylene syringe and a butterfly needle and then 7 ml
blood was transferred to tubes containing ethylenediami-
netetra-acetic acid (10 mg/mL blood). After shaking the
tubes one or two times, we tranferred the blood samples
into the tubes containing aprotinin (0.6 TIU/mL) for
inhibiting proteinase activity. The samples were centri-
fuged at 2,500 rpm at 4C for 15 min. and stored at -70C
until analysis. The extracted plasma was assayed by an
enzyme linked immunosorbent assay (ELISA) using a
commercially available kit (Phoenix Pharmaceuticals,
Karlsruhe, Germany) according to the manufacturers
instructions.
Statistical analysis
Statistical analysis was performed by Statistical Package
for Social Sciences (SPSS) 12.0 (SPSS Inc., Chicago, IL,
USA). Results were expressed as mean and standard
deviation or number and percentage as appropriate. Dif-
ferences in continuous variables were analyzed by
123
Arch Gynecol Obstet (2012) 285:649653
Students t-test and MannWhitney U-test according to the
distribution of data. The significance of differences in the
categorical variables of the two groups was assessed using
Chi-squared test or Fishers exact test, wherever applica-
ble. The relation between Kp-10 levels and the age, ges-
tational week, crown rump length (CRL), gravida, number
of abortions, hemoglobin level, hematocrit, white blood
cell count (WBC), platelet count, AST, ALT and LDH
levels were evaluated by the Pearson correlation test.
Stepwise regression analysis was employed on Kp-10 using
BMI, age, gestational week,and ALT to identify significant
covariates with Kp-10. P values of \0.05 were considered
as statistically significant.
Results
Demographic and the clinical characteristics of the study
and the control groups are demonstrated in Table 1. There
was no significant difference between the groups regarding
the demographic and clinical characteristics except gesta-
tional week. The mean CRL of the study and the control
groups were 13 3 and 13 2 mm, respectively. Birth
weight was lower in the study group than that of the control
group (2,100 1,371 vs. 2,860 1,034 g, p = 0.06). Kp-
10 levels were found to be significantly lower in the study
group compared to those in the control group (391 vs.
5,783 pg/mL; p \ 0.01). Pregnancy outcomes of the
women included in the study were shown in Table 2. In the
study group, 2 cases (10%) of intrauterine growth restric-
tion, 1 (5%) preeclampsia, 5 (25%) preterm deliveries, and
4 (20%) missed abortion cases were noted. In the control
group, 3 (15%) preterm delivery, 1 (5%) preeclampsia, and
1(5%) oligohydramnios were detected. Antenatal compli-
cations were more common in early bleeding group
(p = 0.08).
Pearson correlation analysis was performed to detect the
possible relation between Kp-10 levels and age, gestational
week, CRL, birth weight, gravida, number of abortions,
hemoglobin and hematocrit levels, white blood cell count
(WBC), platelet count, AST, ALT and LDH levels
(Table 3). Only gestational week and ALT levels showed
positive correlation with Kp-10 levels (p = 0.02), but
positive correlation value with birth weight was not sig-
nificant (p = 0.09). BMI (p = 0.02) and ALT levels
(p = 0.02) were the covariants approached statistical sig-
nificance in the regression model fitting of Kp-10.
Discussion
The present study is the first one which showed signifi-
cantly lower Kp-10 levels in women with abortus
Arch Gynecol Obstet (2012) 285:649653 651

Table 1 Demographic and

Characteristics Abortus imminens Control group P value
clinical characteristics of all
(n = 20) (n = 20)
women in the study
Age (years) 29 5 30 5 0.50
BMI (kg/m2) 25 3 24 2 0.26
Gravida (n) 32 42 0.14
Abortion (n) 0 (03) 1 (03) 0.35
Gestational week 10 (718) 13 (1018) 0.01
CRL (mm) 13 3 13 2 0.56
Delivery week 37 (1140) 38 (2141) 0.15
Birthweight (g) 2,100 1,371 2,860 1,034 0.06
Kisspeptin-10 (pg/mL) 391 (152951) 5,783 (3,1689,953) \0.01
Values are expressed as Hemoglobin (g/dl) 12 1 12 1 0.63
means SD and median Hematocrit (%) 34 4 34 4 0.58
(minmax)
WBC (ll-1) 9,419 2,463 8,264 2,368 0.14
BMI body mass index, CRL
crown rump length, WBC white Platelet (mm-3) 9 103 201(151324) 215 (150326) 0.65
blood cell, AST aspartate AST (U/L) 25 10 28 10 0.28
aminotransferase, ALT alanine ALT (U/L) 21 9 26 8 0.08
aminotransferase, LDH lactate
LDH (U/L) 192 71 229 84 0.14
dehydrogenase

Table 2 Pregnancy outcomes

Abortus imminens Control group P value
of both the study and control
n (%) n (%)
groups
Delivery mode 0.04
Vaginal delivery 5 (25) 11 (55)
Cesarean section 11 (55) 9 (45)
Curettage 4 (20) -
Pregnacy complications
Intrauterine growth restriction 2 (10) - 0.08
Preterm delivery 5 (25) 3 (15)
Preeclampsia 1 (5) 1 (5)
Oligohydramnios - 1 (5)
Intrauterine exitus 4 (20) -
Neonatal outcome
Exitus 7 (35) 2 (10) 0.05
Alive 13 (65) 18 (90)

imminens compared to healthy pregnant women. The
biological and clinical value of this difference remains to
be determined. Early pregnancy bleeding was found to be
associated with more preterm deliveries and low birth-
weight infants [15] and in the present study, we also
reported preterm delivery and low birthweight to be more
common in abortus imminens group. A recent study on a
limited number of subjects has reported that circulating
levels of kisspeptin measured early in pregnancy
(814 weeks) were lower in women who later had small
gestational age neonates [16]. Similarly, we also detected
lower birthweight in neonates of women with lower Kp-10
levels and early pregnancy bleeding. Interestingly, kiss-
peptin mRNA levels were found to be higher in the pla-
centa collected from preterm deliveries, although maternal
circulating kisspeptin levels were not different between the
preterm and term deliveries [17]. Lower kisspeptin levels
in pregnancies with preeclampsia and intra-uterine growth
restriction in which reduced invasive capacity would be
expected, was consistent with the hypothesis that low
expression of kisspeptin within the placenta signaled low
invasive capacity [16, 18]. However, Nijher et al. [19]
found no significant correlation between plasma kisspeptin
levels and blood pressure in healthy pregnant women or in
preeclamptics, and no significant difference in plasma
kisspeptin concentrations between women with hyperten-
sive diseases of pregnancy and normotensive pregnant
controls. On the contrary, Armstrong et al. [18] found
lower kisspeptin levels in early gestation (1620 weeks) in
women who subsequently developed preeclampsia and

123
652
Table 3 Correlation analysis of factors in relation with kp-10 levels
Factors R P value
Age 0.203
Gravida 0.227
Abortion 0.186
Gestational week 0.361
Crown rump length 0.065
Birth weight 0.273
Hemoglobin -0.139
Hematocrit -0.109
WBC -0.244
Platelet 0.154
AST 0.225
ALT 0.378
LDH 0.188
WBC white blood cell, AST aspartate aminotransferase, ALT alanine
aminotransferase, LDH lactate dehydrogenase
intrauterine growth restriction compared to controls and
suggested that lower kisspeptin levels in maternal serum in
the second trimester were associated with placental dys-
function. However, another study reported higher KISS1
mRNA and protein expression in trophoblasts from women
with preeclampsia compared with controls and a negative
correlation between KISS1 mRNA expression levels and
birthweight [20]. In our study, we did not observe an
increased preeclampsia incidence in women with lower
Kp-10 levels and only two intrauterine growth restriction
cases were observed in this group. Conflicting results exist
in the literature about kisspeptin and preeclampsia devel-
opment. Further studies with larger patient numbers will
probably give clearer results about preeclampsia develop-
ment in pregnant women with lower Kp-10 levels detected
in early pregnancy. However, lower Kp-10 levels in early
pregnancy were found to be associated with low birth-
weight or small gestational age newborns which might
suggest poor placentation. Our results demonstrated pos-
sible relation between low plasma kisspeptin concentra-
tions and low birthweight. Kisspeptin and its relation to
placentation is still a new topic for investigation and
kisspeptin may be useful in combination with other
markers to identify at-risk pregnancies. A better under-
standing of its mechanism of action may give us a chance
to improve therapeutic strategies to intervene in threatened
early abortion, preterm delivery, preeclampsia and intra-
uterine growth restriction. Of course, determining the pla-
cental levels and mRNA expression pattern of Kp-10 will
develop our understanding on placentation process in
adverse pregnancy outcomes.
Acknowledgments We thank to doctors and nurses of Firat Uni-
versity School of Medicine, Department of Obstetric and Gynecology
123
Arch Gynecol Obstet (2012) 285:649653
for the help provided during our study. This study has been supported
by Firat University Scientific Research Foundation.
Conflict of interest All of the doctors have no conflict of interest.
0.209
0.159
0.251
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