Vascular endothelial growth factor/platelet ratio as a potential biomarker for preeclampsia: A study of angiogenic markers in Pakistani patients

Abstract

Objectives

To determine the levels of angiogenic biomarkers: vascular endothelial growth factor (VEGF), soluble vascular endothelial growth factor receptor 1 (sVEGFR1 or sFlt-1), platelet count, and the VEGF/platelet ratio in preeclampsia.

Methods

Forty-four cases of preeclampsia and 44 controls were recruited.

Results

The serum VEGF, sVEGFR1, and VEGF/platelet ratio were significantly higher and platelet counts lower in preeclampsia in comparison to controls (VEGF: median = 178 vs. 97 pg/mL, p < 0.0001, sVEGFR1: 1634 vs. 627 pg/mL, p < 0.0001, VEGF/platelet ratio: 1.148 vs. 0.417, and platelet count: 178 × 10³/µL vs. 232 × 10³/µL, p = 0.0006). The VEGF and VEGF/platelet ratio showed better diagnostic accuracy for differentiating preeclampsia, with an area under the curve of 97.47% (95% CI: 0.95–1.00) and 89.46% (95% CI: 0.82–0.96), respectively. VEGFA: c.-2055A>C (rs699947) AA genotype exhibited higher serum VEGF levels associated with preeclampsia.

Conclusion

The higher levels of angiogenic biomarkers in preeclampsia, suggest a role in the pathogenesis and potential diagnosis.

Keywords

Platelets preeclampsia soluble vascular endothelial growth factor receptor 1 vascular endothelial growth factor vascular endothelial growth factor/platelet ratio

Introduction

Preeclampsia is a multisystemic disease that affects 3%–5% of pregnancies, leading to increased feto-maternal morbidity and mortality. Although its pathogenesis is poorly understood, placental insufficiency is considered the primary cause. The abnormal cytotrophoblastic infiltration of spiral arterioles and decreased uteroplacental perfusion with subsequent placental hypoxia trigger the secretion of antiangiogenic factors, leading to maternal systemic endothelial dysfunction and hypertension.^1–4

Placental vasculogenesis depends on angiogenic and antiangiogenic factors equilibrium. The vascular endothelial growth factor (VEGF) is a homodimeric glycoprotein and is expressed in macrophages, platelets, and placental cells. Its overexpression may cause vascular endothelial proliferation, which may lead to endothelial damage.^5–7 Previous studies have shown a link between VEGFA gene single nucleotide variants (SNVs) and serum VEGF levels among carriers of VEGFA rs699947, rs833061, rs833070, and rs2010963 variants.^8–10 VEGF-A expression on platelets indicates its source and sensitivity in levels with changes in platelet count. Previous studies have confirmed the association between platelet count and VEGF in autoimmune disorders and cancers. Moreover, platelet depletion and VEGF release in response to acute events suggest a possible inverse correlation between platelet count and VEGF levels.¹¹

The soluble vascular endothelial growth factor receptor-1 (sVEGFR1) also referred to as soluble fms-like tyrosine kinase 1 (sFlt-1), is an antiangiogenic molecule secreted predominantly by the placenta and vascular endothelium. Preeclamptic women have been found to exhibit elevated levels of sVEGFR1 in their placentas, with a subsequent decrease in circulation following delivery. Various studies have suggested the role of sVEGFR1 in preeclampsia, and its utility as a diagnostic marker, particularly in chronic disorders accompanied by hypertension and proteinuria.^12,13 Therefore, studying angiogenic biomarkers in preeclampsia could improve understanding of the underlying mechanisms, provide new insights into physiological changes, and aid in developing novel therapeutic approaches for treating preeclampsia.

The objectives of this study were to determine the serum VEGF, sVEGFR1, and VEGF/platelet ratio in preeclampsia and to compare their levels in normal pregnant women. Additionally, the influence of selected variants of the VEGFA gene on VEGF levels was estimated.

Materials and methods

Subjects

This comparative cross-sectional study was conducted between 2017 and 2021 at the Liaquat University of Medical and Health Sciences, and the University of Sindh, Jamshoro, Pakistan, following Research Ethics Committee approval and obtaining written informed consent. The study included two groups: Group A, with 44 women diagnosed with preeclampsia, and Group B, with 44 normal pregnant women as controls. The control group was matched with cases for age, gestational age, and parity. Only participants who were not in labor, did not take any medications (except vitamin supplements/tonics during pregnancy), were > 20 weeks, gestation, and were followed for 12 weeks after delivery were selected. The estimation of gestational age was determined from the last menstrual period and early ultrasound scan. Based on the mean difference of serum VEGF and sVEGFR1 from previous studies,^14,15 a sample size of n = 88 was considered sufficient to achieve > 80% power.

Clinical criteria

Preeclampsia was defined as a systolic ≥140 mm Hg and a diastolic blood pressure ≥90 mm Hg on the two events, 4 h apart, and proteinuria of ≥0.3 g/24-h or a urine dipstick test ≥1+ after 20 gestational weeks in patients with a previous history of normal blood pressure.¹⁶ Thrombocytopenia was defined as platelet count < 150,000/μL. It was categorized into mild (100,000–150,000/μL), moderate (50,000–<100,000/μL), and severe thrombocytopenia (<50,000/μL). Participants with a history of diabetes mellitus, renal diseases, chronic hypertension, molar pregnancy, multiple pregnancies, gestational diabetes mellitus, thromboembolism, or antiphospholipid syndrome were excluded. Patients with active infection, premature rupture of membranes, in labor, already receiving treatment, lost to follow-up until delivery, presented with postpartum preeclampsia/eclampsia, intrapartum eclampsia, and hemolyzed samples were not included. Figure 1 presents a flow diagram illustrating the recruitment of the study participants.

Figure 1.

Flow diagram illustrating recruitment of the study participants.

Sample collection and measurement of serum VEGF and sVEGFR1

Blood samples were obtained from all participants to analyze the serum total VEGF and sVEGFR1 levels and to extract genomic DNA for genotyping SNVs. The concentrations of VEGF and sVEGFR1 were measured by sandwich enzyme-linked immunosorbent assay (ELISA) quantitative method by using ELISA kits (VEGF: ab100662; sVEGFR1: ab119613; Abcam, Cambridge, MA, USA) in conformity with the manufacturer's instructions. Each sample was analyzed in duplicate, and mean levels were used for the analysis. The detection range of VEGF was 8.23–6000 pg/mL and 156–10,000 pg/mL for sVEGFR1. Intra-assay and inter-assay coefficient variation (CV) were < 10% and < 12%, respectively, for VEGF and < 8% and < 10%, respectively, for sVEGFR1. The biochem ASYS UVM 340 microplate reader (Biochrom Ltd, Cambridge, UK) was used for the detection of the OD value of each well, and the levels of VEGF and sVEGFR1 were calculated by plotting a standard curve.

Determination of VEGFA SNVs

Genotyping of variants VEGFA: c.-2055A > C (rs699947) and VEGFA: c.*237C > T (rs3025039) of the VEGFA gene was performed by the tetra-primer amplification refractory mutation system polymerase chain reaction (ARMS PCR) method, as previously reported.¹⁷

Statistical methods

Categorical variables were reported as frequencies/percentages and analyzed with the Fisher/chi-square test, whereas, non-normal distributed continuous variables with a median/interquartile range (IQR). Mann-Whitney U-test for intergroup comparisons and the Kruskal-Wallis test with Dunn's post hoc test was used for analyzing more than two groups. Normality assumptions were checked graphically and using the Shapiro-Wilk test. To evaluate the correlation among the biomarker concentrations, Spearman's correlation was applied. To determine the cut-off values for biomarkers, receiver operating characteristic (ROC) and associated area under the curve (AUC) were used. The optimal cut-off point was determined by identifying the maximal Youden index (sensitivity + specificity − 1) on the ROC curve. The diagnostic accuracy was reported as sensitivity, specificity, and likelihood ratio (LR+ and LR−). Data was analyzed on GraphPad Prism 9.5.0, and significance was considered at p ≤ 0.05.

Results

Baseline characteristics

Table 1 presents the characteristics of the participants. There were differences in the education level, the number of antenatal visits during the current pregnancy, and the previous and family history of preeclampsia between the preeclampsia and controls (p < 0.05). On the contrary, there were no differences in age at marriage, body mass index (BMI), husband's education level, consanguinity, or family history of hypertension between the study groups, indicating similarities.

Table 1.

Baseline characteristics of study participants.

Characteristics	Preeclampsia	Controls	p
Characteristics	(n = 44)	(n = 44)	p
Age (years)	25 (23–32)	28 (24–30)	0.841^a
Age at marriage	21 (19–24)	22 (19–25)	0.902
Body mass index (kg/m²)	23.3 (20–25.63)	21.5 (20.8–24.03)	0.265
Systolic BP (mm Hg)	150 (140–160)	110 (110–120)	<0.0001
Diastolic BP (mm Hg)	100 (90–110)	80 (80–90)	<0.0001
Platelet count
Normal (150,000–400,000/μL)	27 (61.4)	40 (90.9)	0.004
Mild thrombocytopenia (100,000–150,000/μL)	09 (20.4)	03(6.8)
Moderate thrombocytopenia (50,000–<100,000/μL)	08 (18.2)	01(2.3)
Severe thrombocytopenia (<50,000/μL)	0 (0)	0 (0)
Gestational age in weeks
< 34	16 (36.4)	16 (36.4)	—^a
34–36	13 (29.5)	13 (29.5)
> 36	15 (34.1)	15 (34.1)
Education level
Illiterate	37 (84.1)	30 (68.2)	0.035
Primary	04 (9.1)	13 (29.5)
Matric	02 (4.5)	01 (2.3)
Graduate	01 (2.3)	0 (0)
Husband's education level
Illiterate	25 (56.8)	29 (65.9)	0.535
Primary	09 (20.5)	10 (22.7)
Matric	09 (20.5)	05 (11.4)
Graduate	01 (2.2)	0 (0)
Parity
Primipara	23 (52.3)	23 (52.3)	—^a
Multipara	21 (47.7)	21 (47.7)
Number of antenatal visits
0	10 (22.7)	12 (27.3)	0.042
1–3	22 (50)	10 (22.7)
4–7	08 (18.2)	17 (38.6)
> 7	04 (9.1)	05 (11.4)
Previous history of preeclampsia
Yes	06 (13.6)	0 (0)	0.026
No	38 (86.4)	44 (100)	0.026
Consanguineous marriage
Yes	30 (68.2)	31(70.5)	1.000
No	14 (31.8)	13 (29.5)	1.000
Family history of hypertension
Yes	13 (29.5)	10 (22.7)	0.467
No	31 (70.5)	34 (77.3)	0.467
Family history of preeclampsia
Yes	10 (22.7)	01 (2.3)	0.007
No	34 (77.3)	43 (97.7)
Mode of delivery
Normal vaginal delivery	24	29	0.276
Cesarean section	20	15	0.276
Fetal outcome
Alive	33	44	0.0018
Stillbirth	04	0
Intrauterine death	07	0
Fetal weight (kg)	2.5 (2.1–2.75)	3.15 (3.02–3.42)	0.028

BP: blood pressure; IQR: interquartile range.

Matched variables.

Bold font indicates a significant p-value.

VEGF, sVEGFR1, platelet count, and VEGF/platelet ratio

Serum VEGF, sVEGFR1, and VEGF/platelet ratio were significantly increased in preeclampsia, as compared to the control group (VEGF: 178 vs. 97 pg/mL; p < 0.0001, sVEGFR1: 1634 vs. 627 pg/mL; p < 0.0001, and VEGF/platelet ratio: 1.148 vs. 0.417; p < 0.0001). In contrast, a marked decrease in the platelet count among individuals with preeclampsia as compared to controls (178 × 10³/µL vs. 231.5 × 10³/µL; p = 0.0006) was noted (Table 2). Spearman's correlation showed a moderately negative correlation between serum VEGF and sVEGFR1 among women with preeclampsia (r = −0.4580, p = 0.0026). There was a weak negative correlation between serum VEGF and platelet count in this group (r = −0.3225, p = 0.0327). Though no significant correlation was observed between serum VEGF and either sVEGFR1 (r = −0.1273, p = 0.4529) or platelet count in the control group (r = 0.1128, p = 0.466) (Supplemental Figure 1).

Table 2.

The concentration of angiogenic markers overall and according to gestational age groups among study participants.

Angiogenic markers		Preeclampsia	Controls	p
		(n = 44)	(n = 44)
		Median (IQR)	Median (IQR)
VEGF		178 (147–249)	97 (87–116)	<0.0001
Gestational age	< 34 weeks	169 (134–266)	96 (84–111)	<0.0001
	34–36 weeks	191 (153–275)	91 (82–101)	<0.0001
	> 36 weeks	176 (147–247)	110 (90–133)	<0.0001
sVEGFR1		1634 (814–3689)	627 (529–937)	<0.0001
Gestational age	< 34 weeks	2629 (1522–6492)	764 (572–1102)	<0.0001
	34–36 weeks	1249 (729–3197)	809 (559–1102)	0.08
	> 36 weeks	994 (634–3294)	544 (469–569)	0.01
Platelet count (× 10³/µL)		178 (121–222)	232 (190–290)	0.0006
Gestational age	< 34 weeks	161 (114–212)	245.5 (194–289)	0.0041
	34–36 weeks	168 (109–247)	215 (178–307)	0.066
	> 36 weeks	200 (139–338)	222 (194–285)	0.2903
VEGF/platelet ratio		1.148 (0.752–1.525)	0.417 (0.334–0.511)	<0.0001
Gestational age	< 34 weeks	1.205 (0.8331–1.525)	0.4184 (0.315–0.4495)	<0.0001
	34–36 weeks	1.285 (0.6315–2.571)	0.4186 (0.3165–0.552)	<0.0001
	> 36 weeks	0.9101 (0.6243–1.242)	0.4104 (0.3711–0.6318)	0.0049

IQR: Interquartile range; VEGF: vascular endothelial growth factor; sVEGFR1: soluble vascular endothelial growth factor receptor 1.

Bold fonts indicate significant values.

The levels of angiogenic markers were evaluated in different gestational age groups. The results demonstrated that women with preeclampsia had higher levels of VEGF and a higher VEGF/platelet ratio compared to normal pregnant women within the same gestational age groups. Additionally, significantly higher levels of sVEGFR1 were observed among preeclampsia cases at < 34 and > 36 weeks of gestation. However, no significant differences were observed between preeclampsia and control at 34–36 weeks. Furthermore, sVEGFR1 levels showed a progressive decline in levels descending from < 34, 34–36, and > 36 weeks with a significant difference in the levels observed between < 34 and > 36 weeks on intergroup comparisons among preeclampsia gestational age groups. Platelet count showed a significant difference only in gestational age < 34 weeks between the preeclampsia and control groups. Notably, serum VEGF concentrations were higher after 34 weeks of gestation, while sVEGFR1 levels were elevated before 34 weeks of gestation in preeclampsia.

We also examined the serum VEGF levels according to the severity of thrombocytopenia in the preeclampsia group. The median VEGF levels were significantly higher (p < 0.0001) in preeclampsia with moderate thrombocytopenia compared to mild thrombocytopenia, and normal platelet count. The median (IQR) VEGF levels and platelet count were 174 pg/mL (147–238) and 210 × 10³/µL (186–283) among preeclampsia patients with normal platelet count, 156 pg/mL (136–253) and 125 × 10³/µL (120–143) in patients with mild thrombocytopenia and 275 pg/mL (210–453) and 80 × 10³/µL (68–95) in patients with moderate thrombocytopenia, respectively. Similarly, a higher VEGF/platelet ratio was observed in moderate thrombocytopenia [3.457 (2.282–6.411)] compared to mild thrombocytopenia [1.285 (0.9748–1.954)] and a normal platelet count [0.8065 (0.6149–1.180)] among preeclampsia patients. There was no patient with severe thrombocytopenia in our study group.

ROC-curve analysis

ROC curve demonstrated an AUC of 97.47% (95% CI = 0.95–1.0) for VEGF, 80.27% (95% CI = 0.71–0.9) for sVEGFR1, 70.89% (95% CI = 0.59–0.82) for platelet count, and 89.46% (95% CI = 0.82–0.96) for VEGF/platelet ratio (Table 3 and Figure 2). The best cut-off values were found to be 140.5 pg/mL for VEGF, 1234 pg/mL for sVEGFR1, 210 (×103/µL) for platelet count, and 0.6068 for VEGF/platelet ratio.

Figure 2.

ROC curve showing diagnostic accuracy of serum sVEGFR1, VEGF, platelet count, and VEGF/platelet count ratio in preeclampsia.

Table 3.

Diagnostic accuracy of serum VEGF, sVEGFR1, platelet count, and VEGF/platelet ratio.

Diagnostic accuracy	VEGF	sVEGFR1	Platelet count	VEGF/platelet ratio
Cut-off value	140.5 pg/mL	1234 pg/mL	210 (× 10³/µL)	0.6068
AUC (%)	97.47	80.27	70.89	89.46
95% CI	0.95–1.00	0.71–0.90	0.59–0.82	0.82–0.96
p	<0.0001	<0.0001	0.0007	<0.0001
Sensitivity (%)	97.73	90.91	70.45	86.36
Specificity (%)	86.36	61.36	63.64	81.82
Youden's index (J)	0.84	0.52	0.34	0.68
LR+	7.167	2.353	1.938	4.75
LR−	0.03	0.15	0.46	0.17

AUC: area under the curve; CI: confidence interval; LR: Likelihood ratio; VEGF: vascular endothelial growth factor; sVEGFR1: soluble vascular endothelial growth factor receptor 1

Association of VEGFA variants with serum VEGF levels

We investigated whether the VEGFA gene variants VEGFA: c.*237C > T (rs3025039) and VEGFA: c.-2055A > C (rs699947) impacted serum VEGF levels. The studied SNVs were in alignment with Hardy-Weinberg equilibrium (HWE) and showed no association with preeclampsia (p > 0.05). In preeclampsia, we found that the VEGFA: c.-2055A > C (rs699947) genotypes were significantly associated with serum VEGF levels, with higher levels seen in the AA genotype (p = 0.022) (Supplemental Table 1). Although the highest median VEGF levels were observed with the AA genotype, no differences were observed in association with VEGFA: c.-2055A > C (rs699947) genotypes in the control group. We did not find any association between VEGFA: c.*237C > T (rs3025039) genotypes and serum VEGF.

Discussion

Preeclampsia is related to defects in angiogenesis and remodeling of the trophoblast, leading to abnormal placentation. Despite previous studies demonstrating changes in the serum levels of angiogenic biomarkers in preeclampsia,^7,14 to our knowledge, no study has been conducted to investigate the VEGF/platelet ratio in preeclampsia. Therefore, we determined the serum levels of angiogenic markers (sVEGFR1, VEGF, and platelet count) and the impact of VEGFA gene variants on serum VEGF levels in the Pakistani population.

VEGF is crucial for physiological and pathological angiogenesis, predominantly sequestered in platelets, and functions as a major physiological transporter of it in circulation. Serum VEGF levels display the concentrations of both intra-platelet and plasma, but since the plasma contains considerably lower levels, platelets are the major and primary contributors to the serum VEGF levels. It has been reported that the platelet VEGF load in malignancies is quantitatively linked to tumor expression of VEGF. Serum VEGF concentrations are highly correlated with platelet count, and enhanced coagulation activity may accelerate vasopermeability, leading to extensive VEGF secretion from aggregated platelets. Changes in the VEGF/platelet ratio are indicative of disease activity, suggesting it is more accurate for monitoring disease progression than isolated serum VEGF. Furthermore, the released VEGF plays a crucial role in the disease's etiopathogenesis by causing hypervasopermeability.^18–20 Abnormal coagulation and platelet activation in preeclampsia lead to increased platelet consumption, resulting in thrombocytopenia, which can serve as a critical indicator of this condition. A meta-analysis has demonstrated a significant reduction in platelet count in preeclampsia compared to control groups (mean platelet count: 190.1 × 10⁹/L vs. 232.6 × 10⁹/L, respectively), which is in agreement with the present study findings. In asymptomatic pregnant women, platelet count has been considered a potential indicator of preeclampsia. However, conflicting results have been reported, with some studies showing no difference in platelet count between those who develop preeclampsia and those who do not, while others have found a significant decrease in platelet count.^21,22

We found higher levels of serum VEGF in women with preeclampsia compared to controls, which is consistent with previous research.^15,23–25 Moreover, serum VEGF levels were higher in all gestational age groups in preeclampsia, with the highest level detected between 34 and 36 weeks of gestation, which is consistent with the findings of Kurbanov.²⁴ In contrast, certain previous studies have shown conflicting results and found low VEGF levels in preeclampsia. Lyall et al.²⁶ reported higher median VEGF concentrations in non-pregnant compared to pregnant women, with a further decline in levels in preeclampsia. Additionally, reduced serum VEGF was detected in preeclampsia reported by Arora et al.²⁷ and Tang et al.²⁸ The discrepancies in the findings of VEGF levels among studies may be attributed to several reasons, such as population variation, reporting bound or free serum VEGF, different analytical techniques, epigenetic factors, and the influence of VEGFA gene variants on serum VEGF in various populations. Additionally, the correlation of VEGF with platelet indices in relation to preeclampsia is lacking in studies, which does not reflect the extent of disease activity as thrombocytopenia related to preeclampsia may affect serum VEGF levels. In this study, we found a higher VEGF/platelet ratio in preeclampsia compared to the control group (1.148 vs. 0.417, respectively). The VEGF/platelet ratio showed progressively higher levels among preeclampsia patients, from normal platelet levels to severe thrombocytopenia, with an inverse relation to serum VEGF levels. Thrombocytopenia with increased serum VEGF levels has previously been reported in dengue fever,²⁹ sepsis,³⁰ and hepatocellular carcinoma.¹⁸ However, its role in preeclampsia has not been discussed earlier, and further studies in different populations may be required to understand its potential role as an algorithmic and diagnostic marker for preeclampsia.

Previous studies have shown an association between VEGFA gene variants and serum VEGF levels,^8,27,31 however, their association with preeclampsia has not been widely discussed. We found higher serum VEGF concentrations among participants with the AA genotype of VEGFA: c.-2055A > C (rs699947) variant, with significantly higher levels in the preeclampsia group (p = 0.022). These findings are consistent with those of Bao et al.³² and Al-Habboubi et al.,³³ who reported high serum VEGF levels with the AA genotype of the VEGFA: c.-2055A > C (rs699947) variant. However, we are the first to report higher serum VEGF levels in association with the VEGFA: c.-2055A > C (rs699947) AA genotype in preeclampsia.

Findings from earlier investigations have indicated that sVEGFR1 increases in preeclampsia weeks before hypertension and proteinuria onset, indicating its potential role in pathogenesis, diagnosis, and prediction of preeclampsia. In our study, a significant increase in sVEGFR1 levels in preeclampsia compared to controls is in accordance with other studies.^14,34,35 Furthermore, higher levels of sVEGFR1 in early-onset (< 34 weeks) compared to late-onset preeclampsia,¹⁴ may suggest its implication as a biomarker for early-onset disorder. Other angiogenic markers such as placental growth factor (PLGF) have also been reported for diagnosing and predicting preeclampsia. Though recent research suggests that the sVEGFR1 to PLGF ratio (sFlt-1/PLGF) may provide better diagnostic accuracy than standard clinical measures,^36,37 further investigation into additional biomarkers is required to improve diagnostic accuracy and the construction of an algorithm to diagnose and manage preeclampsia in various populations.

This study has certain limitations, including a small sample size and its restriction to one population. Conducting further research with larger sample sizes, diverse populations, and the inclusion of additional angiogenic markers could yield a more comprehensive understanding of the role of angiogenic markers in preeclampsia.

Conclusion

In conclusion, our study results showed an increased serum VEGF, sVEGFR1, and VEGF/platelet ratio in preeclampsia. These angiogenic biomarkers may provide insight into the pathophysiology of preeclampsia and may aid in the diagnosis and management of the disorder.

Supplemental Material

sj-jpg-1-obm-10.1177_1753495X241234961 - Supplemental material for Vascular endothelial growth factor/platelet ratio as a potential biomarker for preeclampsia: A study of angiogenic markers in Pakistani patients

Supplemental material, sj-jpg-1-obm-10.1177_1753495X241234961 for Vascular endothelial growth factor/platelet ratio as a potential biomarker for preeclampsia: A study of angiogenic markers in Pakistani patients by Feriha Fatima Khidri, Yar Muhammad Waryah, Roohi Nigar, Zaib-Un-Nisa Mughal, Jawaid Ahmed Zai, Ali Raza Rao, Ikram Din Ujjan and Ali Muhammad Waryah in Obstetric Medicine

Supplemental Material

sj-docx-2-obm-10.1177_1753495X241234961 - Supplemental material for Vascular endothelial growth factor/platelet ratio as a potential biomarker for preeclampsia: A study of angiogenic markers in Pakistani patients

Supplemental material, sj-docx-2-obm-10.1177_1753495X241234961 for Vascular endothelial growth factor/platelet ratio as a potential biomarker for preeclampsia: A study of angiogenic markers in Pakistani patients by Feriha Fatima Khidri, Yar Muhammad Waryah, Roohi Nigar, Zaib-Un-Nisa Mughal, Jawaid Ahmed Zai, Ali Raza Rao, Ikram Din Ujjan and Ali Muhammad Waryah in Obstetric Medicine

Footnotes

Acknowledgements

The authors are thankful to the patients for their participation in the study.

Contributorship

FFK: Enrolled patients and controls, Performed Laboratory experiments and statistical analysis, and participated in drafting. YMW, ZM, JAZ, and ARR: Performed laboratory experiments and interpreted the results. RN: participated in patient enrolments, and performed clinical investigations. IDU and AMW: Supervised the laboratory experiments, critical review, and verified the data and manuscript drafting. All authors read and approved the final manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

The study was approved by the Ethical Review Committee of Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan. The study was performed in accordance with the ethical standards as laid down in the Declaration of Helsinki.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan.

Guarantor

Feriha Fatima Khidri.

Informed consent

Written informed consent was obtained from all study participants.

ORCID iD

Feriha Fatima Khidri

Supplemental material

Supplemental material for this article is available online.

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