Research

www. AJOG.org

OBSTETRICS

Maternal plasma 25-hydroxyvitamin D levels,

angiogenic factors, and preeclampsia
Shu-Qin Wei, MD, PhD; Franois Audibert, MD, MSc; Zhong-Cheng Luo, MD, PhD; Anne Monique Nuyt, MD;
Benoit Masse, PhD; Pierre Julien, PhD; William D. Fraser, MD, MSc; and the MIROS Study Group
OBJECTIVE: The objective of the study was to examine the associations

of maternal plasma levels of 25-hydroxyvitamin D [25(OH)D] with angiogenesis and endothelial dysfunction indicators: soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), intercellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1),
and risk of preeclampsia.
STUDY DESIGN: In this prospective cohort study (n 697), maternal

plasma 25(OH)D levels were measured at 12-18 and 24-26 weeks;

sFlt-1, PlGF, ICAM-1, and VCAM-1 levels were measured at 24-26
weeks.
RESULTS: Maternal PlGF levels were significantly lower in women with

25(OH)D less than 50 nmol/L at 12-18 weeks (median, 449.5 vs 507.9

pg/mL, P 0.04) and 24-26 weeks (median, 450.4 vs 522.5 pg/mL,

P 0.007). Both maternal 25(OH)D and PlGF levels were inversely associated with the risk of preeclampsia (both P .05). However, based
on a test of interaction, there was no evidence that the association between vitamin D and preeclampsia depended on the level of PlGF.
CONCLUSION: Maternal vitamin D deficiency is associated with low

PlGF levels and increased preeclampsia risk. However, our data do not
support the hypothesis that the association between vitamin D deficiency and preeclampsia is mediated by impaired angiogenesis.
Key words: 25-hydroxyvitamin D, intercellular adhesion molecule-1,
placental growth factor, preeclampsia, soluble fms-like tyrosine
kinase-1, vascular adhesion molecule-1

Cite this article as: Wei S-Q, Audibert F, Luo Z-C, et al. Maternal plasma 25-hydroxyvitamin D levels, angiogenic factors, and preeclampsia. Am J Obstet Gynecol
2013;208:390.e1-6.

reeclampsia is a pregnancy-specific
multisystem disorder characterized
by de novo-onset high blood pressure
and proteinuria after 20 weeks gestation
complicates 2-8% of all pregnancies and
is a major contributor to maternal and
perinatal mortality and morbidities
(acute and long term).13 Despite intensive efforts to delineate the pathophysi-

ology of preeclampsia, neither its etiology nor its pathogenesis has been clearly
identified.4
Recently epidemiological studies have
demonstrated an association between
low maternal vitamin D status during
pregnancy and the incidence of preeclampsia and suggest that vitamin D deficiency may be an independent risk fac-

From the Departments of Obstetrics and Gynecology (Drs Wei, Audibert, Luo, and Fraser) and
Pediatrics (Dr Nuyt) and the Department of Social and Preventive Medicine (Dr Masse), SainteJustine Hospital, University of Montreal, Montreal, and the Department of Endocrinology and
Nephrology, Centre de Recherche du Centre Hospitalier Universitaire de Qubec, Laval University,
Qubec City (Dr Julien), QC, Canada.
Received Nov. 24, 2012; revised Feb. 4, 2013; accepted March 19, 2013.
This work was supported by research grant 78879 from the Canadian Institutes of Health
Research (CIHR). S.-Q.W. was supported by an award from the CIHR RCT Mentoring Program;
F.A. was supported by a CIHR New Investigator award; Z.-C.L. was supported by a Junior
Scholar award from the Fonds de Recherche en Sante du Quebec and a CIHR New Investigator
award; and W.D.F. was supported by a CIHR Canada Research Chair award.
The authors report no conflict of interest.
The racing flag logo above indicates that this article was rushed to press for the benefit of the
scientific community.
Presented orally at the 33rd annual meeting of the Society for Maternal-Fetal Medicine, San
Francisco, CA, Feb. 11-16, 2013.
Reprints: Shu-Qin Wei, MD, PhD, Department of Obstetrics and Gynecology, Centre Hospitalier
Universitaire Sainte-Justine, Universit de Montral, 5757 Decelles, Montreal, QC, Canada H3S
2C3. shu.qin.wei@umontreal.ca.
0002-9378/$36.00 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.03.025

390.e1

American Journal of Obstetrics & Gynecology MAY 2013

tor for preeclampsia.5,6 However, the

underlying mechanisms remain unknown. Vitamin D deficiency is associated with inflammation-linked vascular
endothelial dysfunction.7 Endothelial
cell damage or dysfunction appears to be
a basic pathophysiological event of the
maternal vascular system in women with
preeclampsia.8,9
The concept of endothelial dysfunction observed in preeclampsia is supported by the findings of a state of angiogenic disturbance10,11 and increased
maternal circulating levels of endothelial
adhesion molecules.12,13 Several biological markers have been used as indicators
of endothelial dysfunction.14 Soluble fmslike tyrosine kinase 1 (sFlt-1) competitively
binds to placental growth factor (PlGF)
and vascular endothelial growth factor
(VEGF), preventing their role in endothelial preservation.15 The placenta produces
sFlt-1 during normal pregnancy, but significantly higher amounts are produced
from the hypoxic placenta in preeclamptic
pregnancies. The presence of these proteins and their effect on PlGF and VEGF
create an angiogenically imbalanced vascular environment that contributes to the

Obstetrics

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endothelial insult occurring in preeclampsia.15 Soluble adhesion molecules including vascular cell adhesion molecule-1
(VCAM-1) and intercellular adhesion
molecule-1 (ICAM-1) have been implicated in the interaction between the trophoblast and the endometrium and can
be expressed in a variety of cells during
inflammation.16 ICAM-1 and VCAM-1
are known to be increased in patients
with preeclampsia, indicating a pathological role of endothelial cell activation
or dysfunction.17
The possible mechanisms by which vitamin D could alter the risk of preeclampsia remain to be elucidated. Recently in vitro studies have indicated that
vitamin D may improve angiogenesis18
and inhibit adhesion molecule expression19 in endothelial cells. However, this
information has not been examined in
vivo. There is a lack of information in
humans as to whether maternal vitamin
D status could influence angiogenesis
and endothelial dysfunction by altering
circulating levels of angiogenic factors
or adhesion molecules and result in
preeclampsia.
The objective of the present study was
to explore the associations between maternal circulating 25-hydroxyvitamin D
[25(OH)D] levels, indicators of angiogenesis and endothelial dysfunction
(sFlt-1, PlGF, ICAM-1 ,VCAM-1) and
the risk of preeclampsia.

M ATERIALS AND M ETHODS

Study design
This prospective cohort study was based
on a data and biological specimens bank
generated in the context of a randomized, placebo-controlled international
trial of antioxidant supplementation (vitamins C and E) for the prevention of
preeclampsia (INTAPP).20 Canadian
INTAPP subjects who were recontacted
and consented to participate in a biobank for further research with maternal
plasma specimen available at the baseline study visit contributed to this study.
The design and the study population
characteristics of this cohort have been
described previously.6 In the INTAPP
trial, women were stratified according to
the presence or absence of risk factors for

preeclampsia. Women were in the highrisk stratum for preeclampsia if they met
at least one of the following 4 criteria: (1)
prepregnancy chronic hypertension (diastolic blood pressure of 90 mm Hg or
greater or the use of an antihypertensive
medication before 20 weeks of gestation); (2) prepregnancy diabetes; (3) a
multiple pregnancy; or (4) a history of
preeclampsia. The remaining women
were nulliparae without other risk factors for preeclampsia (low-risk group).20
Nonfasting maternal blood samples
were collected and banked at 12-18
weeks and 24-26 weeks of gestation. Venous blood was drawn into EDTA tubes,
and plasma samples were immediately
separated by centrifugation at 500 g
for 10 minutes at 4C. Plasma samples
were rapidly frozen and stored at 80C
for future assays.
The study definitions of gestational
hypertension and preeclampsia according to the criteria of the Canadian Hypertension Society Consensus Conference Report21 have been described
previously.6,20 Briefly, gestational hypertension was defined as 2 or more readings of diastolic blood pressure of 90 mm
Hg or greater taken 4 hours apart but
within 72 hours occurring at 20 or more
weeks of gestation.21 Preeclampsia was
defined as gestational hypertension with
proteinuria. Proteinuria was defined as a
urine protein dipstick test 2 or greater
or the urinary excretion of 0.3 g or
greater in 24 hours urine collection.21
Superimposed preeclampsia was defined
according to the guidelines of Canadian
Hypertension Society Consensus Conference Report.21

Laboratory assays
Maternal plasma 25(OH)D levels at
12-18 weeks and 24-26 weeks were measured by a direct, competitive chemiluminescent immunoassay using the DiaSorin LIAISON 25(OH)D TOTAL assay
(DiaSorin, Inc, Stillwater, MN) as described previousely.6 The lower and upper limits of detection for 25(OH)D were
10 nmol/L and 375 nmol/L, respectively.
The coefficient of variation (CV) was
5.2-9.2%.
The biomarkers of angiogenesis and endothelial dysfunction, maternal plasma

Research

sFlt-1, PlGF, ICAM-1, and VCAM-1 were

measured at 24-26 weeks gestation. The
sFlt-1 level was measured by an automated
2-site chemiluminescent immunometric
assay (Beckman-Coulter, Chaska, MN).
PlGF concentration was determined by using a solid phase, 2-site fluorommunometric assay on the DELFIA Xpress 6007-0010
platform (PerkinElmer, Turku, Finland).
The lower limits of detection of the assay
were 5 pg/mL for sFlt-1 and PlGF, and the
CVs were less than 7.7%.
Soluble ICAM-1 and soluble VCAM-1
were measured using the Quantikine human immunoassay kit specific for sICAM-1(CD54) and sICAM-1(CD106)
(R&D Systems, Minneapolis, MN). The
lower limits of detection were 1.6 ng/mL
for sICAM-1 and 6.3 ng/mL for sVCAM-1, with CVs in the range of 2.8
6.0%. All assays were run according to
the protocol specified by the manufacturer. The individuals performing all
study assays were blinded to the participants pregnancy outcome.

Statistical analysis
A Spearman correlation analysis was conducted to examine the association between
maternal plasma 25(OH)D, sFlt-1, PlGF,
ICAM-1, or VCAM-1 concentrations. We
explored the maternal plasma sFlt-1, PlGF,
ICAM-1, and VCAM-1 levels at 24-26
weeks gestation according to maternal vitamin D status at 12-18 weeks and 24-26
weeks of gestation, using the cutoff point
of 50 nmol/L, which has been suggested by
many experts as the cutoff for vitamin D
deficiency.22 The 50 nmol/L cutoff was
consistent with the vitamin D concentrationpreeclampsia risk curve observed in
our study cohort, as previously reported.6
To explore the relationship between
maternal sFlt-1, PlGF, ICAM-1, and
VCAM-1 levels and vitamin D status, the
Wilcoxon rank sum tests were performed for differences in the biomarkers concentration in women in the presence and absence of maternal plasma low
vitamin D status [25(OH)D less than 50
nmol/L vs 50 nmol/L or greater]. The
Wilcoxon rank sum tests were also performed to examine the differences in the
biomarkers levels between preeclamptic
versus nonpreeclamptic women.

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Finally, we conducted logistic regression analyses adjusting for the potential

confounding factors (maternal age, risk
status,6,20 smoking, prepregnancy body
mass index, and season of blood draw) to
estimate the risk (adjusted odds ratio
[aOR] with 95% confidence intervals
[CIs]) of preeclampsia associated with
low vitamin D status. Season of blood
draw was defined according to the dates
of collection of the specimens: winter if
the blood was drawn on November 1
through April 30 (the period of lowest
light exposure in Canada); otherwise, it
was defined as nonwinter.
A final multivariable logistic model
was developed that included biomarkers
that were associated with both vitamin D
and preeclampsia (P .05) to determine
whether the inclusion of the biomarker
altered the relationship between vitamin
D and preeclampsia. We tested for evidence of interaction between 25(OH)D
status and PlGF levels by including a
multiplicative interaction term in the
multivariable logistic model. Two-sided
values of P .05 were considered significant. All analyses were performed using
SAS software, version 9.2 (SAS Institute
Inc, Cary, NC).
The study was approved by the Research Ethics Committees of the participating hospitals.

R ESULTS
There were 697 patients who consented
and contributed specimens to the biobank, among whom 32 (4.6 %) developed preeclampsia including 6 superimposed preeclampsia. The characteristics
of the study population have been described previously.6 A strong positive correlation was observed in maternal
25(OH)D concentrations between 12-18
weeks and 24-26 weeks of gestational age
windows (r 0.69, P .0001). A positive
correlation was demonstrated (r 0.37;
P .0001) between maternal ICAM-1 and
VCAM-1. Maternal 25(OH)D levels at
12-18 weeks and 24-26 weeks of gestation
were positively correlated with PlGF at
24-26 weeks gestation (r 0.10, P .01;
r 0.11, P .01, respectively) (Table 1).
Maternal 25(OH)D level at 12-18 weeks
gestation and ICAM-1 at 24-26 weeks
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TABLE 1

Correlations between 25(OH)D and angiogenesis/endothelial dysfunction

Vitamin D status

sFlt-1

PlGF

ICAM-1

VCAM-1

25(OH)D level at 12-18 weeks gestation

.....................................................................................................................................................................................................................................

0.079

0.102

.08

.01

0.118

0.029

.....................................................................................................................................................................................................................................
a
a

P value

.004

.48

..............................................................................................................................................................................................................................................

25(OH)D level at 24-26 weeks gestation

.....................................................................................................................................................................................................................................

0.047

0.106

.29

.01

0.062

0.010

.....................................................................................................................................................................................................................................
a

P value

.13

.81

..............................................................................................................................................................................................................................................

ICAM-1, intercellular adhesion molecule-1; PlGF, placental growth factor; r, coefficient of correlation; sFlt-1, soluble fms-like
tyrosine kinase-1; 25(OH)D, 25-hydroxyvitamin D; VCAM-1, vascular adhesion molecule-1.
a

P .05.

Wei. Vitamin D, angiogenesis, endothelial dysfunction, and preeclampsia. Am J Obstet Gynecol 2013.

were inversely correlated (r 0.12;

P .004). However, this association was
not observed between maternal levels of
25(OH)D and sFlt-1 or VCAM-1.
Table 2 presents the associations between maternal plasma vitamin D status
(less than 50 nmol/L, 50 nmol/L or
greater) at 12-18 weeks and 24-26 weeks
of gestation and maternal circulating
sFlt-1, PlGF, ICAM-1, VCAM-1 concentrations at 24-26 weeks gestation. Maternal plasma PlGF concentrations at
24-26 weeks were significantly lower in
the pregnant women whose 25(OH)D
levels were less than 50 nmol/L at 12-18
weeks and 24-26 weeks of gestation compared with those were not (median,
449.5 pg/mL vs 507.9 pg/mL, P .04;
450.4 pg/mL vs 522.5 pg/mL, P 0.007,
respectively). Maternal plasma ICAM-1
concentration at 24-26 weeks was significantly higher in the pregnant women
whose 25(OH)D concentrations were
less than 50 nmol/L at 12-18 weeks compared with those were not (median,
211.8 ng/mL vs 196.2 ng/mL, P .02).
However, no significant association was
observed between vitamin D status and
sFlt-1 or VCAM-1 concentrations.
Table 3 presents maternal plasma levels of 25(OH)D and circulating biomarkers in women with preeclampsia vs
women without preeclampsia. Maternal
PlGF concentration was significantly
lower in women with preeclampsia compared with women without preeclampsia (median, 261.6 vs 502.4, P .0001).
Maternal median ICAM-1 concentration was not significantly different in

American Journal of Obstetrics & Gynecology MAY 2013

women with preeclampsia compared

with women without preeclampsia (P
.90). Maternal VCAM-1 concentration
was significantly higher in women with
preeclampsia compared with women
without preeclampsia (median, 507.7 vs
483.5, P .04).
The odds of preeclampsia according to
maternal plasma 25(OH)D and PlGF
concentrations in 24-26 weeks of gestation are presented in Table 4. After adjusting for potential confounding factors
including maternal age, risk group,
smoking, season of blood draw, and
prepregnancy body mass index, maternal 25(OH)D less than 50 nmol/L was
associated with an increased risk of preeclampsia (aOR, 3.24, 95% CI, 1.37
7.69). The addition of the variable PlGF
in the multivariate logistic model mentioned in previous text resulted in a small
reduction (8.3%) in the aOR of preeclampsia for maternal 25(OH)D less
than 50 nmol/L at 24-26 weeks gestation
(aOR, 2.97, 95% CI, 1.237.20).
The log likelihood ratio statistic test
comparing the models with vs without
PlGF showed a statistically significant
difference between models (2, 17.6, P
.001). However, when we tested for interaction between these 2 variables
[25(OH)D less than 50 nmol/L and
PlGF], there was no statistical evidence
of interaction (P .54). Other biomarkers were not included in the final models
because they were not simultaneously
associated with both vitamin D status
and preeclampsia.

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Research

TABLE 2

Angiogenesis/endothelial dysfunction levels by vitamin D status

Biomarkers

Vitamin D status

Median (interquartile range)

Mean SD

P valuea

12-18 weeks gestation

.......................................................................................................................................................................................................................................................................................................................................................................

sFlt-1, pg/mL

25(OH)D 50 nmol/L

2074.4 (1196.63332.3)

2799.3 2371.8

25(OH)D 50 nmol/L

2384.6 (1275.23987.8)

3879.8 6147.2

25(OH)D 50 nmol/L

449.5 (277.6832.1)

653.8 635.2

25(OH)D 50 nmol/L

507.9 (334.7933.3)

754.1 729.3

25(OH)D 50 nmol/L

211.8 (173.9247.2)

215.9 61.2

25(OH)D 50 nmol/L

196.2 (172.3234.0)

204.4 53.3

25(OH)D 50 nmol/L

498.8 (411.1590.7)

514.2 148.4

25(OH)D 50 nmol/L

474.8 (404.5579.9)

503.1 143.8

.06

.........................................................................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................................................................................................................................................
b

PlGF, pg/mL

.04

.........................................................................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................................................................................................................................................
b

ICAM-1, ng/mL

.02

.........................................................................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................................................................................................................................................

VCAM-1, ng/mL

.24

.........................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................

24-26 weeks gestation

.......................................................................................................................................................................................................................................................................................................................................................................

sFlt-1, pg/mL

25(OH)D 50 nmol/L

2190.1 (1336.53813.4)

3912.7 7132.2

25(OH)D 50 nmol/L

2230.0 (1230.83925.9)

3218.2 3403.5

25(OH)D 50 nmol/L

450.4 (271.6805.8)

637.9 638.7

.81

.........................................................................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................................................................................................................................................
b

PlGF, pg/mL

.007

.........................................................................................................................................................................................................................................................................................

25(OH)D 50 nmol/L

522.5 (344.7985.0)

766.7 727.1

25(OH)D 50 nmol/L

205.9 (174.1242.8)

211.9 55.4

25(OH)D 50 nmol/L

197.6 (172.3234.8)

206.9 57.5

25(OH)D 50 nmol/L

493.2 (407.7591.0)

509.9 136.6

25(OH)D 50 nmol/L

477.2 (406.1574.8)

505.4 150.9

.......................................................................................................................................................................................................................................................................................................................................................................

ICAM-1, ng/mL

.18

.........................................................................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................................................................................................................................................

VCAM-1, ng/mL

.46

.........................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................

ICAM-1, intercellular adhesion molecule-1; PlGF, placental growth factor; sFlt-1, soluble fms-like tyrosine kinase-1; 25(OH)D, 25-hydroxyvitamin D; VCAM-1, vascular adhesion molecule-1.
a

P values in Wilcoxon rank sum tests for differences in biomarker concentrations in women with 25(OH)D less than 50 nmol/L versus 50 nmol/L or greater; b P .05.

Wei. Vitamin D, angiogenesis, endothelial dysfunction, and preeclampsia. Am J Obstet Gynecol 2013.

When we performed a sensitivity analysis

excluding women with chronic hypertension (n 41), similar results were observed.

C OMMENT
Preeclampsia has been hypothesized to
be a 2-stage disorder.23 The 2-stage
model of preeclampsia proposes that

stage 1 involves reduced placental perfusion and the release of circulating factors
that result in peripheral endothelial dysfunction and, ultimately, the clinical features of preeclampsia (stage 2).23 Epidemiological studies from our group and
others have shown that preeclampsia is
associated with vitamin D deficiency.5,6

TABLE 3

25(OH)D and angiogenesis/endothelial dysfunction in preeclampsia and

nonpreeclampsia
Variable
25(OH)D, nmol/L

Preeclampsia
Mean SD, median

Nonpreeclampsia
Mean SD, median

48.9 16.8, 46.4

57.0 19.1, 56.5

P valuea
.03b

..............................................................................................................................................................................................................................................

sFlt-1, pg/mL

9083.2 16105.4, 2750.4

3168.4 3472.1, 2147.1

.08

..............................................................................................................................................................................................................................................
b

PlGF, pg/mL

374.7 369.4, 261.6

733.7 703.8, 502.4

.0001

ICAM-1, ng/mL

216.9 78.2, 196.8

208.6 55.5, 202.7

.90

VCAM-1, ng/mL

615.5 256.1, 507.7

502.1 136.1, 483.5

.04

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
b
..............................................................................................................................................................................................................................................

ICAM-1, intercellular adhesion molecule-1; PlGF, placental growth factor; sFlt-1, soluble fms-like tyrosine kinase-1; 25(OH)D,
25-hydroxyvitamin D; VCAM-1, vascular adhesion molecule-1.
a

P values in Wilcoxon rank sum tests for differences in preeclamptic vs nonpreeclamptic women; b P .05.

Wei. Vitamin D, angiogenesis, endothelial dysfunction, and preeclampsia. Am J Obstet Gynecol 2013.

However, the mechanisms by which vitamin D might exert its effect remain
unknown.
We observed that pregnant women
with plasma 25(OH)D levels less than 50
nmol/L had a significantly decreased
concentration of PlGF. This observation
strengthens the plausibility of an association between vitamin D deficiency and
preeclampsia by confirming its association with a biomarker likely to be involved in the pathophysiology of the disease. However, it remains uncertain
whether the observed association between vitamin D status and preeclampsia
act through impaired angiogenesis or
through other mechanisms.
To examine whether PlGF influences
the relationship between vitamin D status and preeclampsia, we created multivariable logistic models that excluded
and included PlGF. There was evidence
that the 2 models differed statistically;
however, the inclusion of PlGF resulted
in only a small reduction (8.3%) in the

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strength of association between vitamin

D and preeclampsia. To further explore
whether the effect of vitamin D on the
risk of preeclampsia depends on PlGF
levels, an interaction test was performed.
We found no statistical evidence of interaction between vitamin D and PlGF levels for preeclampsia. Women with
plasma 25(OH)D levels less than 50
nmol/L had a significantly increased
concentration of ICAM-1. However,
VCAM-1 but not ICAM-1 levels were associated with preeclampsia in our cohort, and there was no evidence of significant association of VCAM-1 with
vitamin D levels.
Recently studies have indicated that
vitamin D is a novel and important mediator in endothelial cell function and
dysfunction.24,25 Both observational and
interventional studies have established
an association between vitamin D levels
and endothelial dysfunction.24 Nonpregnant subjects with vitamin D deficiency had significantly lower flow mediated dilatation (an indicator of
endothelial function) than those with vitamin D levels in the normal range) and
showed improvement after treatment
with vitamin D.26 Vascular endothelial
cells express both 1-alpha-hydroxylase
and vitamin D receptor, suggesting that
vitamin D is an important mediator of
vascular endothelial function.27,28
A recent study has indicated that altered maternal levels of angiogenic factors resulted in impaired angiogenesis
and led to endothelial damage.15 Moreover, in cell culture models, vitamin D
has been shown to improve the angiogenic properties of endothelial progenitor cells.18 In our prospective cohort,
women with vitamin D deficiency had a
reduced level of PlGF, which was associated with an increased risk of preeclampsia. However, our data do not provide
statistical support for a mediating role of
PlGF in the association between vitamin
D and preeclampsia.
Our study also showed that vitamin D
deficiency was associated with increased
levels of ICAM-1. This finding is consistent with in vitro studies.29,30 Incubation
of the cultured endothelial cells and human umbilical vein cord endothelial cells
with 1,25-dihydroxyvitamin D3 inhibits
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TABLE 4

Odds ratios of preeclampsia in association with 25(OH)D and indicators

of angiogenesis/endothelial dysfunction
Variables

Unadjusted
OR (95% CI)

Adjusted
OR (95% CI)a

Adjusted
OR (95% CI)b

25(OH)D 50 nmol/L

3.49 (1.557.86)

3.24 (1.377.69)

2.97 (1.237.20)

sFlt-1, per SD increase

1.55 (1.231.96)

1.63 (1.272.09)

PlGF, per SD increase

0.22 (0.080.60)

0.19 (0.060.54)

0.20 (0.070.58)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

ICAM-1, per SD increase

1.15 (0.811.64)

0.99 (0.661.49)

VCAM-1, per SD increase

1.77 (1.322.38)

1.75 (1.282.41)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

The high-risk group included patients with chronic hypertension, prepregnancy diabetes, multiple pregnancy, or a history of
preeclampsia; the low-risk group included nulliparous patients without other known risk factors for preeclampsia.
CI, confidence interval; ICAM-1, intercellular adhesion molecule-1; OR, odds ratio; PlGF, placental growth factor; sFlt-1,
soluble fms-like tyrosine kinase-1; 25(OH)D, 25-hydroxyvitamin D; VCAM-1, vascular adhesion molecule-1.
a

Adjusting for maternal age, risk group, smoking, season of blood draw, and prepregnancy body mass index; b In the final model
including maternal vitamin D status, age, risk group, smoking, season of blood draw, prepregnancy body mass index and PlGF;
log likelihood ratio statistic test comparing the models with vs without PlGF: 2 17.6, P .001.

Wei. Vitamin D, angiogenesis, endothelial dysfunction, and preeclampsia. Am J Obstet Gynecol 2013.

tumor necrosis factor--induced adhesion molecule expression in endothelial

cells.29 Vitamin D decreased ICAM-1 expression on pulmonary microvascular
endothelial cells and neutrophil motivation.30 However, ICAM-1 levels were not
observed to be associated with preeclampsia in our data.
Epidemiological observations from
preeclampsia in association with vitamin
D deficiency currently lack clearly defined pathways to explain this relationship.31 Our data do not allow us to
clearly elucidate the mechanisms involved. Multivariable models have welldocumented limitations as the means to
explore causal relationships.32 In addition, statistical tests for interaction are
frequently underpowered. These results
must be interpreted with caution. The
absence of evidence of interaction between vitamin D and PlGF in the current
study does not provide firm grounds to
reject a mediating effect of PlGF in the
association between vitamin D and
preeclampsia.
Our study has several methodological
strengths. First, it is a prospective pregnancy cohort that explores the vitamin D
status at different gestational age windows and the association with the risk of
subsequent preeclampsia. Second, maternal plasma specimens were collected
before the clinical manifestations of preeclampsia were evident.

American Journal of Obstetrics & Gynecology MAY 2013

A limitation of this study is the lack of

data on other angiogenic factors such as
soluble endoglin. We also have no data
on calcium status. The vitamin D endocrine system is pivotal for calcium homeostasis and the principal physiological function recognized for vitamin D is
enhancing calcium absorption, and calcium supplementation has been associated with a reduced risk of preeclampsia.33 However, a recent study has
questioned the association between
25(OH)D concentrations and calcium
absorption efficiency.34
In summary, the results of our longitudinal pregnancy cohort study demonstrate an association between maternal
vitamin D deficiency and reduced levels
of PlGF, a biomarker that is strongly associated with preeclampsia. However,
our results do not support the hypothesis
that vitamin D and PlGF share a common causal pathway in the pathogenesis
of preeclampsia.
To better elucidate the mechanism by
which vitamin D may have an impact on
the pathophysiology of preeclampsia,
phase II clinical trials to assess the effects
of vitamin D supplementation among
pregnant woman with vitamin D deficiency are needed. This would allow the
unbiased assessment of the impact of vitamin D supplementation on a range of
biomarkers, including markers of angiogenesis, reflecting potential pathological

Obstetrics

www.AJOG.org
processes in preeclampsia. Such studies
should be undertaken prior to implementing large, double-blinded, randomized controlled trials of vitamin D supplementation for the prevention of
preeclampsia.
f
ACKNOWLEDGMENTS
We thank the nursing and medical staffs at all
study participating hospitals.

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