Perspective

Genetics of pre-eclampsia and the weight of babies at birth – clinical

and genetic studies in Sri Lanka
V H W Dissanayake1

(Index words: pre-eclampsia, birthweight, MTHFR, F2, F5, EGF, AGT, TGFA)

Background Candidate gene disease association studies, on the

other hand, can be performed anywhere. These studies
Pre-eclampsia is the de novo occurrence of
involve prospectively recruiting cases and controls from
hypertension and proteinuria in pregnancy in an otherwise
a population, selecting a candidate gene and the genetic
normal woman [1]. Recent advances in genetics has
markers in or near the candidate gene, and then determining
resulted in a surge of investigations into genetic factors
whether the marker is found more commonly in cases than
underlying pre-eclampsia [2, 3]. These studies have been in controls using molecular genetic tests. This was the
conducted mainly among western Europeans and approach we selected for our studies of the genetics of
Japanese. The investigations reviewed in this paper were pre-eclampsia in Sri Lanka.
undertaken in a genetically distinct South Asian Sinhalese
population in Sri Lanka. Genetic markers are genetic variations. There are
various types of genetic markers. The preferred markers
Complex disorders such as pre-eclampsia are caused for case control studies are single nucleotide
by low penetrant, high frequency genetic variations in polymorphisms or single base changes in the genome [8].
several genes interacting with each other and the There are two ways of selecting candidate genes. First,
environment [2]. As a result the genetic basis of pre- positional candidates, i.e. genes located in genomic regions
eclampsia is not immediately clear [4]. Genetic traces of identified by genome wide linkage screens. Second,
pre-eclampsia could, however, be unmasked through functional candidates, i.e. genes that code for any protein
epidemiological studies, twin studies, and pedigree that is involved in the pathophysiological pathway of pre-
analysis using special techniques [5]. Epidemiological eclampsia [2].
studies show that both maternal and paternal genes, acting Candidate gene disease association studies have
through the foetus, may contribute to the development of been the popular method used to study genetics of pre-
pre-eclampsia [6]. Twin studies confirm this [7], and eclampsia. Many candidate genes across the genome have
pedigree studies report that the pattern of inheritance of been studied using this approach [3]. However, a limitation
pre-eclampsia is consistent with an autosomal dominant of these studies has been that the results in one population
pattern with reduced penetrance [4]. have not been consistently reproducible in other
Two strategies can be used to identify genes causing populations – an important consideration in true
pre-eclampsia - linkage studies and candidate gene disease associations. There are four main reasons for this. Firstly,
association studies [5]. Linkage studies involve recruiting there are issues relating to the definition of pre-eclampsia
because blood pressure and urinary protein are variable
families with multiple affected members, and then
measurements. Establishing the diagnosis involves
identifying regions of the genome that are co-inherited
passing pre-defined thresholds or cut offs on which there
along with pre-eclampsia within the family using molecular
has been some controversy [9, 10] prior to the adoption of
genetic tests to analyse their DNA. There have been
new guidelines by the International Society for the Study
several genome wide linkage screens for pre-eclampsia. of Hypertension in 2001 [1]. Secondly, researchers fail to
Genetic loci harbouring a gene or genes involved in pre- rigorously phenotype cases. Some medical conditions and
eclampsia are as follows: 4q, 2p13, 2p25, 9p13 [2]. However obstetric states are known to increase the risk of
there is little overlap between the loci identified in different development of pre-eclampsia. Therefore, careful
populations in these screens, possibly because of genetic phenotyping is necessary when recruiting cases and
differences in populations. This highlights the importance controls for these studies. Thirdly, there is the possibility
of carrying out genetic studies in different parts of the of population admixture, i.e. the presence of different
world. However, it is not possible to carry out linkage inbreeding subpopulations within cases and controls. This
studies in many parts of the world because medical and could happen when careful attention is not paid to
geneological records that are necessary to ascertain such determination of the ethnicity of recruits and when cases
families are not widely available. and controls are not matched for ethnicity. Finally, most

1
Human Genetics Unit, Faculty of Medicine, University of Colombo, Sri Lanka.
Correspondence: VHWD, e-mail <vajirahwd@hgucolombo.org>. Received 6 August 2008 and revised version accepted
10 January 2009. Competing interests: none declared.

90 Ceylon Medical Journal

 Perspective

studies do not have sufficient numbers of cases and that the birthweight of babies born to women who had
controls, making them underpowered to detect any genetic uncomplicated pregnancies was associated with the
effect [11]. We were mindful of these problems when we mother's epidermal growth factor genotype [15].
began our studies into the genetics of pre-eclampsia in Sri The maternal-fetal interface in pregnancy is unique.
Lanka. It is the only site in an organism where genes from the
mother and genes from the father, acting through the
Genetic studies in Sri Lanka foetus, interact. To study this interaction the genetic make
up of the father, the mother and the foetus or the baby –
By applying a strict definition for pre-eclampsia and the so called parent-child trios – has to be investigated
rigorous exclusion criteria, we recruited a group of women [17, 18]. When we genotyped these trios and analysed
who were carefully phenotyped for pre-eclampsia. The the data we found that chromosomes that contained the
issue of population admixture was addressed as far as 61G and 2566A alleles of the EGF gene or the 61G/2566A
possible [12,13,14]. A sample size of 180 cases and 180
haplotype which is associated with lower birthweight, was
controls was calculated to have adequate power to detect
preferentially transmitted by heterozygous parents to their
a doubling of risk of pre-eclampsia when the susceptibility
growth restricted babies [15].
allele of the genetic marker that increased pre-eclampsia
risk ranged from 0.1 to 0.5, using a dominant model, at a
significance level of p=0.05 with 80% power. Conclusions
Our findings may have important implications when
Candidate gene studies taken in the context of the Barker hypothesis [19]. The
premise of the Barker hypothesis is that adult onset
We selected candidate genes after a review of
disorders have origins in foetal life. Birthweight, which is
scientific writing. They were methylenetetrahydrofolate
the surrogate marker for development in foetal life, is an
reductase (MTHFR), prothrombin (Factor II, F2), factor V
important predictor of health. Low birthweight is related
(F5), angiotensinogen (AGT), transforming growth factor
to an increased risk of diseases in adult life, including
alpha (TGFA), epidermal growth factor (EGF). We selected
cardiovascular disease, hypertension and diabetes. It
both positional (TGFA and EGF) and functional (MTHFR,
raises the question, therefore, whether the epidermal
F2, F5, TGFA, EGF, AGT) candidates. We selected genes
growth factor gene could be the link between low
that have been studied previously (MTHFR, F2, F5, AGT)
birthweight and adult onset disorders. If it turns out to be
and genes that have not been studied previously (TGFA
so, epidermal growth factor would be a potential molecular
and EGF). Next we selected the genetic markers. They
target for targeted therapy to prevent these adult onset
were all single nucleotide polymorphisms. They were as
disorders.
follows: MTHFR 677C>T, 1298A>C, 1317T>C, 1793G>A;
F2 20210G>A; F51691G>A, 4070A>G; TGFA 3822G>A;
3827T>C, 3851T>C; EGF 61G>A, 2566G>A;AGT 174T>M, Acknowledgements
235M>T, 11535C>A.
I wish to acknowledge my supervisors, co-
Results of genotyping the population based DNA investigators, obstetricians at the De Soysa Hospital for
collection for the genetic markers showed that MTHFR Women and the Castle Street Hospital for women (2001 -
1317T>C and F2 20210G>A were not polymorphic in our 2003) and their staff, the women who took part in these
population [15,16]. The susceptibility allele frequencies investigations, Prof. Rohan Jayasekara for critical appraisal
of the Tamils and Moors were similar to that of the
of the manuscript, and funding from the President's Fund
Sinhalese. Therefore, any unsuspected population
of Sri Lanka, University of Colombo, University of
admixture would not affect the results of our candidate
Nottingham, SLMA Glaxo-Welcome Research Award 2001,
gene disease association studies. The results of our
National Science Foundation Grant No: 2004/SIDA/BT/
candidate gene disease association studies showed that
01 and IRQUE project research grants, Faculty of Medicine,
the G allele of the 2566G>A polymorphisms in the EGF
Colombo 2006.
gene increased the risk of pre-eclampsia. Women who were
homozygous for the allele had almost doubling of risk
[OR (95% CI) = 1.87 (1.05-3.31) [17]. References
1. Brown MA, Lindheimer MD, de Swiet M, et al. The
Genetics of birth weight classification and diagnosis of the hypertensive disorders of
pregnancy: statement from the International Society for the
The collection of extensive clinical and genetic data
Study of Hypertension in Pregnancy (ISSHP). Hypertension
opens up opportunities for innovative analyses. We
in Pregnancy 2001; 20: IX-XIV.
decided to explore the contribution of genetic variants to
the weight of babies at birth. The birthweight of babies 2. Chappell S, Morgan L. Searching for genetic clues to the causes
born to women with pre-eclampsia is usually low. We found of pre-eclampsia. Clinical Science 2006; 110: 443-58.

Vol. 54, No. 3, September 2009 91

Perspective

3. Lachmeijer AM, Dekker GA, Pals G, et al. Searching for test for proteinuria in pregnancy in developing countries: a
pre-eclampsia genes: the current position. European Journal method validation study. British Journal of Obstetrics and
of Obstetrics and Gynaecology and Reproductive Biology Gynaecology 2004; 111: 491-4.
2002; 105: 94-113.
13. Dissanayake VHW, Samarasinghe D, Morgan L, et al. An
4. Arngrimsson R, Bjornsson H, Geirsson RT. Analysis of analysis of the reasons for non-participation of subjects
different inheritance patterns in pre-eclampsia/eclampsia referred for recruitment for the Inherited Factors in Pre-
syndrome. Hypertension in Pregnancy 1995; 14: 27-38. eclampsia study (IFPE Study). Sri Lanka Journal of
Obstetrics and Gynaecology 2004; 26: 28-9.
5. Lander ES, Schork NJ. Genetic dissection of complex traits.
Science 1994; 265: 2037-48. 14. Dissanayake VHW, Samarasinghe HD, Morgan L, et al.
Morbidity and mortality associated with pre-eclampsia at
6. Esplin MS, Fausett MB, Fraser A, et al. Paternal and two tertiary care hospitals in Sri Lanka. Journal of Obstetrics
maternal components of the predisposition to pre-eclampsia. and Gynaecology Research 2007; 33: 56-62.
New England Journal of Medicine 2001; 344: 867-72.
15. Dissanayake VHW, Tower C, Broderick A, et al. Poly-
7. Salone Ros H, Lichtenstein P, Lipworth L, Cnattingius S. morphism in the epidermal growth factor gene is associated
Genetic effects on the liability of developing pre-eclampsia with birthweight in Sinhalese and white western Europeans.
and gestational hypertension. American Journal of Medical Molecular Human Reproduction 2007; 13: 425-9.
Genetics 2000; 91: 256-60.
16. Dissanayake VHW, Jayasekara RW, Seneviratne HR, et al.
8. Gray IC, Campbell DA, Spurr NK. Single nucleotide A study of three candidate genes for pre-eclampsia in a
polymorphisms as tools in human genetics. Human Sinhalese population from Sri Lanka. Journal of Obstetrics
Molecular Genetics 2000; 9: 2403-8. and Gynaecology Research. In press.

9. Redman CW, Jefferies M. Revised definition of pre- 17. Mitchell LE. Differentiating between fetal and maternal
eclampsia. Lancet 1988; 1: 809-12. genotypic effects, using the transmission test for linkage
disequilibrium. American Journal of Human Genetics 1997;
10. Davey DA, MacGillivray I. The classification and definition 60: 1006-7.
of the hypertensive disorders of pregnancy. American
Journal of Obstetrics and Gynaecology 1988; 158: 892-8. 18. Spielman RS, McGinnis RE, Ewens WJ. Transmission test
for linkage disequilibrium: the insulin gene region and insulin-
11. Lalouel JM, Rohrwasser A. Power and replication in case- dependent diabetes mellitus (IDDM). American Journal of
control studies. American Journal of Hypertension 2002; Human Genetics 1993; 52: 506-16.
15: 201-5.
19. Barker DJ, Winter PD, Osmond C, et al. Weight in infancy
12. Dissanayake VHW, Morgan L, Broughton Pipkin F, et al. and death from ischaemic heart disease. Lancet 1989; 2:
The urine protein heat coagulation test – a useful screening 577-80.

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