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Gil MM, Cuenca-Gómez D, Rolle V, Pertegal M, Díaz C, Revello R, Adiego B, Mendoza M, Molina FS, Santacruz B, Ansbacher-Feldman Z, Meiri H, Martin-Alonso R, Louzoun Y, De Paco Matallana C. Validation of machine-learning model for first-trimester prediction of pre-eclampsia using cohort from PREVAL study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:68-74. [PMID: 37698356 DOI: 10.1002/uog.27478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/28/2023] [Accepted: 08/15/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE Effective first-trimester screening for pre-eclampsia (PE) can be achieved using a competing-risks model that combines risk factors from the maternal history with multiples of the median (MoM) values of biomarkers. A new model using artificial intelligence through machine-learning methods has been shown to achieve similar screening performance without the need for conversion of raw data of biomarkers into MoM. This study aimed to investigate whether this model can be used across populations without specific adaptations. METHODS Previously, a machine-learning model derived with the use of a fully connected neural network for first-trimester prediction of early (< 34 weeks), preterm (< 37 weeks) and all PE was developed and tested in a cohort of pregnant women in the UK. The model was based on maternal risk factors and mean arterial blood pressure (MAP), uterine artery pulsatility index (UtA-PI), placental growth factor (PlGF) and pregnancy-associated plasma protein-A (PAPP-A). In this study, the model was applied to a dataset of 10 110 singleton pregnancies examined in Spain who participated in the first-trimester PE validation (PREVAL) study, in which first-trimester screening for PE was carried out using the Fetal Medicine Foundation (FMF) competing-risks model. The performance of screening was assessed by examining the area under the receiver-operating-characteristics curve (AUC) and detection rate (DR) at a 10% screen-positive rate (SPR). These indices were compared with those derived from the application of the FMF competing-risks model. The performance of screening was poor if no adjustment was made for the analyzer used to measure PlGF, which was different in the UK and Spain. Therefore, adjustment for the analyzer used was performed using simple linear regression. RESULTS The DRs at 10% SPR for early, preterm and all PE with the machine-learning model were 84.4% (95% CI, 67.2-94.7%), 77.8% (95% CI, 66.4-86.7%) and 55.7% (95% CI, 49.0-62.2%), respectively, with the corresponding AUCs of 0.920 (95% CI, 0.864-0.975), 0.913 (95% CI, 0.882-0.944) and 0.846 (95% CI, 0.820-0.872). This performance was achieved with the use of three of the biomarkers (MAP, UtA-PI and PlGF); inclusion of PAPP-A did not provide significant improvement in DR. The machine-learning model had similar performance to that achieved by the FMF competing-risks model (DR at 10% SPR, 82.7% (95% CI, 69.6-95.8%) for early PE, 72.7% (95% CI, 62.9-82.6%) for preterm PE and 55.1% (95% CI, 48.8-61.4%) for all PE) without requiring specific adaptations to the population. CONCLUSIONS A machine-learning model for first-trimester prediction of PE based on a neural network provides effective screening for PE that can be applied in different populations. However, before doing so, it is essential to make adjustments for the analyzer used for biochemical testing. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M M Gil
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
- Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - D Cuenca-Gómez
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
- Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - V Rolle
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
- Clinical Research Unit, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
| | - M Pertegal
- Department of Obstetrics and Gynecology, Hospital Clínico Universitario 'Virgen de la Arrixaca', El Palmar, Murcia, Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, Murcia, Spain
- Faculty of Medicine, Universidad de Murcia, Murcia, Spain
| | - C Díaz
- Department of Obstetrics and Gynecology, Complejo Hospitalario Universitario A Coruña, A Coruña, Galicia, Spain
| | - R Revello
- Department of Obstetrics and Gynecology, Hospital Universitario Quirón, Pozuelo de Alarcón, Madrid, Spain
| | - B Adiego
- Obstetrics and Gynecology Department, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - M Mendoza
- Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebrón, Barcelona, Catalonia, Spain
| | - F S Molina
- Department of Obstetrics and Gynecology, Hospital Universitario San Cecilio, Granada, Spain
- Instituto de Investigación Biosanitaria (Ibs.GRANADA), Granada, Spain
| | - B Santacruz
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
- Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | | | - H Meiri
- The ASPRE Consortium and TeleMarpe, Tel Aviv, Israel
| | - R Martin-Alonso
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
- Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Y Louzoun
- Department of Mathematics, Bar Ilan University, Ramat Gan, Israel
| | - C De Paco Matallana
- Department of Obstetrics and Gynecology, Hospital Clínico Universitario 'Virgen de la Arrixaca', El Palmar, Murcia, Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, Murcia, Spain
- Faculty of Medicine, Universidad de Murcia, Murcia, Spain
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Rolnik DL, Syngelaki A, O'Gorman N, Wright D, Nicolaides KH, Poon LC. Aspirin for evidence-based preeclampsia prevention trial: effects of aspirin on maternal serum pregnancy-associated plasma protein A and placental growth factor trajectories in pregnancy. Am J Obstet Gynecol 2023:S0002-9378(23)02190-7. [PMID: 38151219 DOI: 10.1016/j.ajog.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/14/2023] [Accepted: 12/20/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND The exact mechanism by which aspirin prevents preeclampsia remains unclear. Its effects on serum placental biomarkers throughout pregnancy are also unknown. OBJECTIVE To investigate the effects of aspirin on serum pregnancy-associated plasma protein A and placental growth factor trajectories using repeated measures from women at increased risk of preterm preeclampsia. STUDY DESIGN This was a longitudinal secondary analysis of the Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-based Preeclampsia Prevention trial using repeated measures of pregnancy-associated plasma protein A and placental growth factor. In the trial, 1620 women at increased risk of preterm preeclampsia were identified using the Fetal Medicine Foundation algorithm at 11 to 13+6 weeks of gestation, of whom 798 were randomly assigned to receive aspirin 150 mg and 822 to receive placebo daily from before 14 weeks to 36 weeks of gestation. Serum biomarkers were measured at baseline and follow-up visits at 19 to 24, 32 to 34, and 36 weeks of gestation. Generalized additive mixed models with treatment by gestational age interaction terms were used to investigate the effect of aspirin on biomarker trajectories over time. RESULTS Overall, there were 5507 pregnancy-associated plasma protein A and 5523 placental growth factor measurements. Raw pregnancy-associated plasma protein A values increased over time, and raw placental growth factor increased until 32 weeks of gestation followed by a decline. The multiple of the median mean values of the same biomarkers were consistently below 1.0 multiple of the median, reflecting the high-risk profile of the study population. Trajectories of mean pregnancy-associated plasma protein A and placental growth factor multiple of the median values did not differ significantly between the aspirin and placebo groups (aspirin treatment by gestational age interaction P values: .259 and .335, respectively). CONCLUSION In women at increased risk of preterm preeclampsia, aspirin 150 mg daily had no significant effects on pregnancy-associated plasma protein A or placental growth factor trajectories when compared to placebo.
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Affiliation(s)
- Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia.
| | - Argyro Syngelaki
- Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| | - Neil O'Gorman
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - David Wright
- Institute of Health Research, University of Exeter, Exeter, United Kingdom
| | - Kypros H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| | - Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong SAR
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3
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Borna S, Ashrafzadeh M, Ghaemi M, Eshraghi N, Hivechi N, Hantoushzadeh S. Correlation between PAPP-A serum levels in the first trimester of pregnancy with the occurrence of gestational diabetes, a multicenter cohort study. BMC Pregnancy Childbirth 2023; 23:847. [PMID: 38082246 PMCID: PMC10712163 DOI: 10.1186/s12884-023-06155-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the association between first-trimester Pregnancy-associated plasma protein A (PAPP-A) levels and subsequent gestational diabetes mellitus (GDM) development. METHOD The study was conducted on 5854 pregnant women who attended routine prenatal care. Maternal biomarkers, including PAPP-A and free beta hCG, were measured for all women in a referral laboratory and converted to MoM values. Pregnant women were divided into two groups, based on the serum concentration of PAPP-A, (PAPP-A > 0.4 (normal) and PAPP-A < 0.4 (low)). Data on the screening test for GDM and pregnancy outcomes were collected and analyzed with appropriate tests. RESULT Of the 5854 pregnant women, 889 (15.19%) developed GDM. The maternal PAPP-A MoM concentrations were significantly lower in GDM cases compared to controls. Indeed, gestational age at delivery and birth weight were significantly lower (p < 0.001) in PAPP-A MoM < 0.4, and the rate of intrauterine growth restriction (IUGR) was significantly higher (p < 0.001). ROC analysis revealed that the sensitivity and specificity of MoM concentration for predicting GDM were 53.3% and 51.9%, respectively. CONCLUSION Lower maternal PAPP-A in early pregnancy can lead to glucose intolerance and increase the risk of subsequent GDM development. In addition, decreased serum concentration of PAPP-A is significantly correlated to lower birth weight and IUGR.
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Affiliation(s)
- Sedigheh Borna
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoumeh Ashrafzadeh
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Marjan Ghaemi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Eshraghi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nafiseh Hivechi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sedigheh Hantoushzadeh
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
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4
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Huang T, Bellai-Dussault K, Meng L, Hull D, Howley H, Reszel J, Lanes A, Walker M, Armour C, Okun N, Dougan S. First and second trimester maternal serum markers for prenatal aneuploidy screening: an update on the adjustment factors for race, smoking, and insulin dependent diabetes mellitus. Clin Biochem 2023:110596. [PMID: 37295638 DOI: 10.1016/j.clinbiochem.2023.110596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 05/24/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The concentrations of maternal serum markers for aneuploidy screening are influenced by maternal characteristics such as race, smoking, insulin dependent diabetes mellitus (IDDM), and in vitro fertilization (IVF). Accurate risk estimation requires adjustment of initial values for these characteristics. This study aims to update and validate adjustment factors for race, smoking, and IDDM. METHODS The study included singleton pregnancies that received multiple marker screening in Ontario, Canada between January 2012, and December 2018, and had their information collected in the Better Outcomes Registry & Network (BORN) Ontario. Serum markers assessed included first trimester pregnancy-associated plasma protein A (PAPP-A), free β and total human chorionic gonadotropin (hCG), placental growth factor (PlGF) and αlpha-fetoprotein (AFP); second trimester AFP, unconjugated estriol (uE3), total hCG and inhibin A. The Mann-Whitney U test was used to assess the differences in the median multiple of the median (MoM) of serum markers between study and reference groups. New adjustment factors were generated by dividing the median MoM of a particular race, individuals who smoke tobacco, or have IDDM by those of the reference groups. RESULTS The study included 624,789 pregnancies. There were statistically significant differences in serum marker concentrations among pregnant individuals who were Black, Asian, or First Nations compared to a Caucasian group, those who smoked compared to Non-smoking individuals, and those with IDDM compared to Non-IDDM group. New adjustment factors for race, smoking, and IDDM were validated by comparing median MoM of serum markers corrected using the current adjustment factors and new adjustment factors generated in this study. CONCLUSION The adjustment factors generated in this study can adjust the effects of race, smoking, and IDDM on serum markers more accurately.
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Affiliation(s)
- Tianhua Huang
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada; Genetics Program, North York General Hospital, Toronto, Ontario, Canada; Department of Obstetrics & Gynaecology, University of Toronto, Toronto, Ontario, Canada.
| | - Kara Bellai-Dussault
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada
| | - Lynn Meng
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada
| | - Danna Hull
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada
| | - Heather Howley
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada
| | - Jessica Reszel
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada
| | - Andrea Lanes
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada
| | - Mark Walker
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics, Gynecology & Newborn Care, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Christine Armour
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Nan Okun
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada; Maternal Fetal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Shelley Dougan
- Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada
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5
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Johnson JM, Walsh JD, Okun NB, Metcalfe A, Pastuck ML, Maxey CM, Soliman N, Mahallati H, Kuret VH, Dwinnell SJ, Chada R, O'Quinn CP, Schacher J, Somerset DA, Paterson K, Suchet IB, Silang KA, Paul H, Nerenberg KA, Johnson DW. The Implementation of Preeclampsia Screening and Prevention (IMPRESS) Study. Am J Obstet Gynecol MFM 2023; 5:100815. [PMID: 36400421 DOI: 10.1016/j.ajogmf.2022.100815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Preeclampsia affects between 2% and 5% of pregnancies and is one of the leading causes of perinatal morbidity and mortality worldwide. Despite strong evidence that the combination of systematic preeclampsia screening based on the Fetal Medicine Foundation preeclampsia risk calculation algorithm with treatment of high-risk patients with low-dose aspirin reduces the incidence of preterm preeclampsia more than currently used risk-factor-based screening, real-world implementation studies have not yet been done in Canada. OBJECTIVE This study aimed to assess the operational feasibility of implementing first-trimester screening and prevention of preterm preeclampsia (<37 weeks) alongside a publicly funded first-trimester combined screening program for aneuploidies. STUDY DESIGN This was a prospective implementation study. Consecutive pregnant patients referred for first-trimester combined screening (11-13+6 weeks) were offered screening for preeclampsia based on the Fetal Medicine Foundation algorithm concomitantly with their aneuploidy screen. Consenting participants were screened using maternal risk factors, mean arterial pressure, uterine artery Doppler pulsatility index, pregnancy-associated plasma protein-A, and placental growth factor. Risk for preterm preeclampsia (<37 weeks) was calculated using the Fetal Medicine Foundation algorithm, and individuals with a risk score ≥1 per 100 were recommended to use aspirin (162 mg once daily at bedtime, <16-36 weeks). Implementation metrics assessed included: acceptability, operational impact, proportion of aspirin initiation, quality and safety measures, and screen performance. RESULTS Between December 1, 2020 and April 23, 2021, 1124 patients consented to preeclampsia screening (98.3% uptake), and 92 (8.2%) screened positive. Appointments for patients receiving first-trimester combined screening aneuploidy and preeclampsia screening averaged 6 minutes longer than first-trimester combined screening alone, and adding uterine artery Doppler pulsatility index averaged 2 minutes. Of the 92 patients who screened as high-risk for preeclampsia, 72 (78.3%) were successfully contacted before 16 weeks' gestation. Of these, 62 (86.1%) initiated aspirin, and 10 (13.9%) did not. Performance audit identified a consistent negative bias with mean arterial pressure measurements (median multiple of the median <1 in 10%); other variables were satisfactory. There were 7 cases of preterm preeclampsia (0.69%): 5 and 2 in the high- and low-risk groups, respectively. Screening detected 5 of 7 (71.4 %) preterm preeclampsia cases, with improved performance after adjustment for aspirin treatment effect. CONCLUSION This study confirms the operational feasibility of implementing an evidence-based preeclampsia screening and prevention program in a publicly funded Canadian setting. This will facilitate implementation into clinical service and the scaling up of this program at a regional and provincial level.
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Affiliation(s)
- J M Johnson
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset).
| | - Jennifer D Walsh
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - Nanette B Okun
- Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada (Dr Okun)
| | - Amy Metcalfe
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - Melanie L Pastuck
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - Connor M Maxey
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - Nancy Soliman
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - Houman Mahallati
- Radiology (Drs Mahallati, Paterson, and Suchet), Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Verena H Kuret
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - Shannon J Dwinnell
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - Rati Chada
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - Candace P O'Quinn
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - Jaime Schacher
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - David A Somerset
- Departments of Obstetrics and Gynecology (Drs J Johnson and Walsh, Ms Pastuck, Dr Metcalfe, Mr Maxey, and Drs Soliman, Kuret, Dwinnell, Chada, O'Quinn, Schacher, and Somerset)
| | - Kimiko Paterson
- Radiology (Drs Mahallati, Paterson, and Suchet), Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ian B Suchet
- Radiology (Drs Mahallati, Paterson, and Suchet), Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Katherine A Silang
- Department of Psychology, University of Calgary, Calgary, Canada (Ms Silang)
| | - Heather Paul
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada (Dr Paul)
| | - Kara A Nerenberg
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada (Dr Nerenberg)
| | - David W Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Canada (Dr D Johnson)
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Frye LJ, Buhimschi IA, Raymond EG, Zhao G, Winikoff B. PAPP-A as a screening tool for assessment of gestational age before medication abortion in an intended-use population. Biomark Med 2023; 17:73-85. [PMID: 37038980 PMCID: PMC10183995 DOI: 10.2217/bmm-2022-0653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/15/2023] [Indexed: 04/12/2023] Open
Abstract
Introduction: Prior studies indicate that PAPP-A could serve as a marker of gestational age (GA) with the potential to determine eligibility for medication abortion. The authors validated the relationship between PAPP-A and GA in an actual-use population. Materials & methods: The authors collected blood samples, medical histories and ultrasound-determined GA from patients presenting for abortion services. They measured PAPP-A using two immunoassays and assessed diagnostic accuracy for predicting GA ≥71 days. Results: The Ansh Labs and R&D Systems immunoassays produced an area under the ROC curve of 0.982 (95% CI: 0.958-0.994) and 0.986 (95% CI: 0.963-0.996), respectively, for predicting GA ≥71 days. Conclusion: This validation study in an intended-use population confirmed that PAPP-A has a strong ability to distinguish pregnancies above and below 71 days' gestation. Clinical trial registration: NCT04232189 (ClinicalTrials.gov).
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Affiliation(s)
- Laura J Frye
- Gynuity Health Projects, 220 East 42nd Street New York, NY 10017, USA
| | - Irina A Buhimschi
- Department of Obstetrics & Gynecology, University of Illinois at Chicago College of Medicine, Chicago, IL 60612, USA
| | | | - Guomao Zhao
- Department of Obstetrics & Gynecology, University of Illinois at Chicago College of Medicine, Chicago, IL 60612, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street New York, NY 10017, USA
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7
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Mazanowska N, Jarmużek-Orska P, Pietrzak B, Pazik J, Jabiry-Zieniewicz Z, Kosiński P. First-Trimester Biochemical Serum Markers in Female Kidney Transplant Recipients-The Impact of Graft Function. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16352. [PMID: 36498421 PMCID: PMC9740865 DOI: 10.3390/ijerph192316352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/27/2022] [Accepted: 12/02/2022] [Indexed: 06/17/2023]
Abstract
Data on serum biochemistry markers as a component of the first-trimester screening test in pregnant kidney graft recipients are limited. In the absence of a separate validated algorithm, biochemical testing is commonly used in the first-trimester screening in kidney transplant recipients. Therefore, the study aimed to analyze first-trimester serum biochemical markers and the first trimester combined screening results in pregnant kidney graft recipients. A retrospective study was carried out in pregnant women who underwent the first-trimester combined screening test performed per the Fetal Medicine Foundation (FMF) protocol in 2009−2020. The study group included 27 pregnancies in kidney graft transplant recipients, and the control group was 110 patients with normal kidney function, matched according to age, body mass index (BMI), and gestational age. The biochemical serum markers (free beta-human chorionic gonadotropin [beta-hCG] and pregnancy-associated plasma protein A [PAPP-A]) were evaluated using the FMF-approved Roche Elecsys® assay and exhibited as multiples of the median (MoM) values. Data on first-trimester screening test results, perinatal outcomes, and graft function (assessed using serum creatinine concentrations) were analyzed. The analysis of first-trimester screening parameters revealed no difference in nuchal translucency (NT) measurements and uterine artery flow. However, free beta-hCG MoM and PAPP-A values were higher in posttransplant pregnancies than in controls: 3.47 ± 2.08 vs. 1.38 ± 0.85 (p = 0.035) and 1.46 ± 0.81 vs. 0.98 ± 0.57 (p = 0.007), respectively. The false positive rate of trisomy 21 (T21) screening in graft recipients was 25.9% vs. 3% in the controls. The free β-hCG MoM values positively correlated with serum creatinine levels before (r = 0.653; p < 0.001), during (r = 0.619; p = 0.001), and after pregnancy (r = 0.697; p < 0.001). There was a statistically significant negative correlation for PAPP-A MoM values for postpartum serum creatinine concentration (r = −0.424, p = 0.035). Our results show significantly higher serum concentrations of free beta-hCG and PAPP-A in posttransplant pregnancies than in healthy controls, confirmed when exhibited as MoM values and their association with graft function was assessed by serum creatinine concentration. Taking those changes into account would reduce the high number of false positive test results in this group. The validated first-trimester screening algorithm that considers altered kidney function in pregnant kidney graft recipients remains to be developed.
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Affiliation(s)
- Natalia Mazanowska
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, pl. Starynkiewicza 1/3, 02-015 Warszawa, Poland
| | - Patrycja Jarmużek-Orska
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, pl. Starynkiewicza 1/3, 02-015 Warszawa, Poland
| | - Bronisława Pietrzak
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, pl. Starynkiewicza 1/3, 02-015 Warszawa, Poland
| | - Joanna Pazik
- Department of Transplantation Medicine and Nephrology, Medical University of Warsaw, 02-015 Warszawa, Poland
| | - Zoulikha Jabiry-Zieniewicz
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, pl. Starynkiewicza 1/3, 02-015 Warszawa, Poland
| | - Przemysław Kosiński
- Department of Obstetrics, Perinatology and Gynecology, Medical University of Warsaw, 02-091 Warszawa, Poland
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8
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Ansbacher-Feldman Z, Syngelaki A, Meiri H, Cirkin R, Nicolaides KH, Louzoun Y. Machine-learning-based prediction of pre-eclampsia using first-trimester maternal characteristics and biomarkers. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:739-745. [PMID: 36454636 DOI: 10.1002/uog.26105] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To evaluate the accuracy of predicting the risk of developing pre-eclampsia (PE) according to first-trimester maternal demographic characteristics, medical history and biomarkers using artificial-intelligence and machine-learning methods. METHODS The data were derived from prospective non-interventional screening for PE at 11-13 weeks' gestation at two maternity hospitals in the UK. The data were divided into three subsets. The first set, including 30 437 subjects, was used to develop the training process, the second set of 10 000 subjects was utilized to optimize the machine-learning hyperparameters and the third set of 20 352 subjects was coded and used for model validation. An artificial neural network was used to predict from the demographic characteristics and medical history the prior risk that was then combined with biomarker values to determine the risk of PE and preterm PE with delivery at < 37 weeks' gestation. An additional network was trained without including race as input. Biomarkers included uterine artery pulsatility index (UtA-PI), mean arterial blood pressure (MAP), placental growth factor (PlGF) and pregnancy-associated plasma protein-A. All markers were entered using raw values without conversion into standardized multiples of the median. The prediction accuracy was estimated using the area under the receiver-operating-characteristics curve (AUC). We further computed the detection rate at 10%, 20% and 40% false-positive rates (FPR). The impact of taking aspirin was also added. Shapley values were calculated to evaluate the contribution of each parameter to the prediction of risk. We used a non-parametric test to compare the expected AUC with the one obtained when we randomly scrambled the labels and kept the predictions. For the general prediction, we performed 10 000 permutations of the labels. When the AUC was higher than the one obtained in all 10 000 permutations, we reported a P-value of < 0.0001. For the race-specific analysis, we performed 1000 permutations. When the AUC was higher than the AUC in permutations, we reported a P-value of < 0.001. RESULTS The detection rate for preterm PE vs no PE, at a 10% FPR, was 53.3% when screening by maternal factors only, and the corresponding AUC was 0.816; these increased to 75.3% and 0.909, respectively, with the addition of biomarkers into the model. Information on race was important for the prediction accuracy; when race was not used to train the model, at a 10% FPR, the detection rate of preterm PE vs no PE decreased to 34.5-45.5% (for different races) when screening by maternal factors only and to 55.0-62.1% when biomarkers were added. The major predictors of PE were high MAP and UtA-PI, and low PlGF. The accuracy of prediction of all PE cases was lower than that for preterm PE. Aspirin use was recommended for cases who were at high risk of preterm PE. The AUC of all PE vs no PE was 0.770 when screening by maternal factors and 0.817 when the biomarkers were added; the respective detection rates, at a 10% FPR, were 41.3% and 52.9%. CONCLUSIONS Screening for PE using a non-linear machine-learning-based approach does not require a population-based normalization, and its performance is similar to that of logistic regression. Removing race information from the model reduces its prediction accuracy, especially for the non-white populations when only maternal factors are considered. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
| | - A Syngelaki
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - H Meiri
- The ASPRE Consortium and TeleMarpe, Tel Aviv, Israel
| | - R Cirkin
- Department of Mathematics, Bar Ilan University, Ramat Gan, Israel
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Y Louzoun
- Department of Mathematics, Bar Ilan University, Ramat Gan, Israel
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9
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Wei Y, He A, Tang C, Liu H, Li L, Yang X, Wang X, Shen F, Liu J, Li J, Li R. Risk prediction models of gestational diabetes mellitus before 16 gestational weeks. BMC Pregnancy Childbirth 2022; 22:889. [PMID: 36456970 PMCID: PMC9714187 DOI: 10.1186/s12884-022-05219-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 11/15/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) can lead to adverse maternal and fetal outcomes, and early prevention is particularly important for their health, but there is no widely accepted approach to predict it in the early pregnancy. The aim of the present study is to build and evaluate predictive models for GDM using routine indexes, including maternal clinical characteristics and laboratory biomarkers, before 16 gestational weeks. METHODS A total of 2895 pregnant women were recruited and maternal clinical characteristics and laboratory biomarkers before 16 weeks of gestation were collected from two hospitals. All participants were randomly stratified into the training cohort and the internal validation cohort by the ratio of 7:3. Using multivariable logistic regression analysis, two nomogram models, including a basic model and an extended model, were built. The discrimination, calibration, and clinical validity were used to evaluate the models in the internal validation cohort. RESULTS The area under the receiver operating characteristic curve of the basic and the extended model was 0.736 and 0.756 in the training cohort, and was 0.736 and 0.763 in the validation cohort, respectively. The calibration curve analysis showed that the predicted values of the two models were not significantly different from the actual observations (p = 0.289 and 0.636 in the training cohort, p = 0.684 and 0.635 in the internal validation cohort, respectively). The decision-curve analysis showed a good clinical application value of the models. CONCLUSIONS The present study built simple and effective models, indicating that routine clinical and laboratory parameters can be used to predict the risk of GDM in the early pregnancy, and providing a novel reference for studying the prediction of GDM.
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Affiliation(s)
- Yiling Wei
- grid.412601.00000 0004 1760 3828Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Andong He
- grid.412601.00000 0004 1760 3828Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Chaoping Tang
- grid.417009.b0000 0004 1758 4591Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150 China
| | - Haixia Liu
- grid.412601.00000 0004 1760 3828Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Ling Li
- Department of Obstetrics and Gynecology, Jiangmen Maternity and Child Health Care Hospital, Jiangmen, 529000 China
| | - Xiaofeng Yang
- grid.412601.00000 0004 1760 3828Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Xiufang Wang
- grid.412601.00000 0004 1760 3828Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Fei Shen
- Department of Obstetrics and Gynecology, Jiangmen Maternity and Child Health Care Hospital, Jiangmen, 529000 China
| | - Jia Liu
- grid.412601.00000 0004 1760 3828Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Jing Li
- Department of Obstetrics and Gynecology, Jiangmen Maternity and Child Health Care Hospital, Jiangmen, 529000 China
| | - Ruiman Li
- grid.412601.00000 0004 1760 3828Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
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10
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Huang T, Bedford HM, Rashid S, Rasasakaram E, Priston M, Mak-Tam E, Gibbons C, Meschino WS, Cuckle H, Mei-Dan E. Modified multiple marker aneuploidy screening as a primary screening test for preeclampsia. BMC Pregnancy Childbirth 2022; 22:190. [PMID: 35260099 PMCID: PMC8903171 DOI: 10.1186/s12884-022-04514-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 02/16/2022] [Indexed: 11/11/2022] Open
Abstract
Background Abnormal levels of maternal biochemical markers used in multiple marker aneuploidy screening have been associated with adverse pregnancy outcomes. This study aims to assess if a combination of maternal characteristics and biochemical markers in the first and second trimesters can be used to screen for preeclampsia (PE). The secondary aim was to assess this combination in identifying pregnancies at risk for gestational hypertension and preterm birth. Methods This case-control study used information on maternal characteristics and residual blood samples from pregnant women who have undergone multiple marker aneuploidy screening. The median multiple of the median (MoM) of first and second trimester biochemical markers in cases (women with PE, gestational hypertension and preterm birth) and controls were compared. Biochemical markers included pregnancy-associated plasma protein A (PAPP-A), placental growth factor (PlGF), human chorionic gonadotropin (hCG), alpha feto-protein (AFP), unconjugated estriol (uE3) and Inhibin A. Logistic regression analysis was used to estimate screening performance using different marker combinations. Screening performance was defined as detection rate (DR) and false positive rate (FPR). Preterm and early-onset preeclampsia PE were defined as women with PE who delivered at < 37 and < 34 weeks of gestation, respectively. Results There were 147 pregnancies with PE (81 term, 49 preterm and 17 early-onset), 295 with gestational hypertension, and 166 preterm birth. Compared to controls, PE cases had significantly lower median MoM of PAPP-A (0.77 vs 1.10, p < 0.0001), PlGF (0.76 vs 1.01, p < 0.0001) and free-β hCG (0.81 vs. 0.98, p < 0.001) in the first trimester along with PAPP-A (0.82 vs 0.99, p < 0.01) and PlGF (0.75 vs 1.02, p < 0.0001) in the second trimester. The lowest first trimester PAPP-A, PlGF and free β-hCG were seen in those with preterm and early-onset PE. At a 20% FPR, 67% of preterm and 76% of early-onset PE cases can be predicted using a combination of maternal characteristics with PAPP-A and PlGF in the first trimester. The corresponding DR was 58% for gestational hypertension and 36% for preterm birth cases. Conclusions Maternal characteristics with first trimester PAPP-A and PlGF measured for aneuploidy screening provided reasonable accuracy in identifying women at risk of developing early onset PE, allowing triage of high-risk women for further investigation and risk-reducing therapy. This combination was less accurate in predicting women who have gestational hypertension or preterm birth.
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Affiliation(s)
- Tianhua Huang
- Genetics Program, North York General Hospital, 4001 Leslie Street, Toronto, ON, M2K 1E1, Canada. .,Prenatal Screening Ontario, Better Outcomes Registry & Network (BORN) Ontario, Ottawa, ON, Canada. .,Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada.
| | - H Melanie Bedford
- Genetics Program, North York General Hospital, 4001 Leslie Street, Toronto, ON, M2K 1E1, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Shamim Rashid
- Genetics Program, North York General Hospital, 4001 Leslie Street, Toronto, ON, M2K 1E1, Canada
| | - Evasha Rasasakaram
- Genetics Program, North York General Hospital, 4001 Leslie Street, Toronto, ON, M2K 1E1, Canada
| | - Megan Priston
- Genetics Program, North York General Hospital, 4001 Leslie Street, Toronto, ON, M2K 1E1, Canada
| | - Ellen Mak-Tam
- Genetics Program, North York General Hospital, 4001 Leslie Street, Toronto, ON, M2K 1E1, Canada
| | - Clare Gibbons
- Genetics Program, North York General Hospital, 4001 Leslie Street, Toronto, ON, M2K 1E1, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Wendy S Meschino
- Genetics Program, North York General Hospital, 4001 Leslie Street, Toronto, ON, M2K 1E1, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Howard Cuckle
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elad Mei-Dan
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada.,Maternal and Newborn Program, North York General Hospital, Toronto, ON, Canada
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11
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Rolnik DL, Selvaratnam RJ, Wertaschnigg D, Meagher S, Wallace E, Hyett J, da Silva Costa F, McLennan A. Routine first trimester combined screening for preterm preeclampsia in Australia: A multicenter clinical implementation cohort study. Int J Gynaecol Obstet 2021; 158:634-642. [PMID: 34837224 DOI: 10.1002/ijgo.14049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/25/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess pregnancy outcomes following first trimester combined screening for preterm preeclampsia in Australia. METHODS We compared pregnancy outcomes of women with singleton pregnancies who underwent first trimester combined preeclampsia screening with the Fetal Medicine Foundation algorithm between 2014 and 2017 in Melbourne and Sydney, Australia, with those from women who received standard care. The primary outcomes were preterm preeclampsia and screening performance. Effect estimates were presented as risk ratios with 95% confidence intervals. RESULTS A total of 29 618 women underwent combined screening and 301 566 women received standard care. Women who had combined screening were less likely to have preeclampsia, preterm birth, small neonates, and low Apgar scores than the general population. Women with high-risk results (≥1 in 100) were more likely to develop preterm preeclampsia (2.1% vs. 0.7%, risk ratio [RR] 3.04, 95% CI 2.46-3.77), while low-risk women (risk <1 in 100) had lower rates of preterm preeclampsia (0.2% vs. 0.7%, RR 0.26, 95% CI 0.19-0.35) and other pregnancy complications. Screening detected 65.2% (95% CI 56.4-73.2%) of all preterm preeclampsia cases, with improved performance after adjustment for treatment effect. CONCLUSIONS First trimester screening for preeclampsia in clinical practice identified a population at high risk of adverse pregnancy outcomes and low-risk women who may be suitable for less intensive antenatal care.
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Affiliation(s)
- Daniel L Rolnik
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University, Clayton, Victoria, Australia
| | - Roshan J Selvaratnam
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University, Clayton, Victoria, Australia.,Department of Health and Human Services, Safer Care Victoria, Victorian Government, Victoria, Australia
| | | | - Simon Meagher
- Monash Ultrasound for Women, Melbourne, Victoria, Australia
| | - Euan Wallace
- Department of Health and Human Services, Melbourne, Victoria, Australia
| | - Jon Hyett
- Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Maternal Fetal Medicine Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Fabricio da Silva Costa
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University, Clayton, Victoria, Australia.,Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Andrew McLennan
- Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Sydney Ultrasound for Women, Sydney, New South Wales, Australia
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12
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Shen L, Martinez-Portilla RJ, Rolnik DL, Poon LC. ASPRE trial: risk factors for development of preterm pre-eclampsia despite aspirin prophylaxis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:546-552. [PMID: 33998099 DOI: 10.1002/uog.23668] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To examine the possible risk factors amongst maternal characteristics, medical and obstetric history, pre-eclampsia (PE)-specific biomarkers and estimated-risk group, according to The Fetal Medicine Foundation (FMF) algorithm, that are associated with the development of preterm PE with delivery at < 37 weeks' gestation despite aspirin prophylaxis. METHODS This was a secondary analysis of data from the ASPRE trial. The study population consisted of women with singleton pregnancy who were deemed to be at high risk for preterm PE, based on the FMF algorithm that combines maternal factors, mean arterial pressure, uterine artery pulsatility index, serum pregnancy-associated plasma protein-A and placental growth factor (PlGF) at 11-13 weeks' gestation. High-risk women were randomized to receive aspirin (150 mg/day) vs placebo from 11-14 until 36 weeks' gestation. The primary outcome was PE with delivery at < 37 weeks' gestation (preterm PE). Multivariate logistic regression analysis was performed to identify independent predictors of preterm PE after adjusting for the use of aspirin and other covariates. RESULTS Among 1592 high-risk women, the incidence of preterm PE was 3.0% (n = 48). The interaction between aspirin usage and history of chronic hypertension was significant in the prediction of preterm PE (P = 0.042), which indicated that there was no treatment effect in high-risk women who had chronic hypertension compared with those who did not. Adjusting for aspirin use, the interaction between aspirin and chronic hypertension and other covariates, independent predictors for the development of preterm PE were PlGF multiples of the median (MoM) (adjusted odds ratio (aOR), 0.226 (95% CI, 0.070-0.723)) and estimated-risk group based on the FMF algorithm. Compared to women with an estimated risk of 1 in 51 to 1 in 100, those with an estimated risk of 1 in 2 to 1 in 10 had a 7-fold higher risk of developing preterm PE (aOR, 6.706 (95% CI, 2.381-18.883)), and those with an estimated risk of 1 in 11 to 1 in 50 had a 3-fold higher risk of preterm PE (aOR, 2.769 (95% CI, 1.105-6.939)). PlGF MoM was an independent predictor for preterm PE among women with an estimated risk of 1 in 2 to 1 in 10 (aOR, 0.055 (95% CI, 0.005-0.668)). Among women with an estimated risk of 1 in 11 to 1 in 100, the use of aspirin was an independent predictor of preterm PE (aOR, 0.276 (95% CI, 0.111-0.689)). The cut-off for PlGF with the best performance for the prediction of preterm PE was 0.712 MoM, with an aOR of 3.677 (95% CI, 1.526-8.862). CONCLUSION In pregnancies at high risk of preterm PE identified by screening at 11-13 weeks' gestation using the FMF algorithm, a very high-risk result (estimated risk ≥ 1 in 50), compared to an estimated risk of 1 in 51 to 1 in 100, chronic hypertension, compared to no chronic hypertension, and low PlGF concentration (< 0.712 MoM), compared to PlGF ≥ 0.712 MoM, were associated with the development of preterm PE despite aspirin prophylaxis. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L Shen
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - R J Martinez-Portilla
- Clinical Research Division, National Institute of Perinatology "Isidro Espinosa de lo Reyes", Mexico City, Mexico
- Iberoamerican Research Network in Obstetrics, Gynecology and Translational Medicine, Mexico City, Mexico
- Fetal Medicine Research Center, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Spain
| | - D L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - L C Poon
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
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13
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Rojas-Rodriguez R, Ziegler R, DeSouza T, Majid S, Madore AS, Amir N, Pace VA, Nachreiner D, Alfego D, Mathew J, Leung K, Moore Simas TA, Corvera S. PAPPA-mediated adipose tissue remodeling mitigates insulin resistance and protects against gestational diabetes in mice and humans. Sci Transl Med 2021; 12:12/571/eaay4145. [PMID: 33239385 DOI: 10.1126/scitranslmed.aay4145] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 04/25/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022]
Abstract
Pregnancy is a physiological state of continuous adaptation to changing maternal and fetal nutritional needs, including a reduction of maternal insulin sensitivity allowing for appropriately enhanced glucose availability to the fetus. However, excessive insulin resistance in conjunction with insufficient insulin secretion results in gestational diabetes mellitus (GDM), greatly increasing the risk for pregnancy complications and predisposing both mothers and offspring to future metabolic disease. Here, we report a signaling pathway connecting pregnancy-associated plasma protein A (PAPPA) with adipose tissue expansion in pregnancy. Adipose tissue plays a central role in the regulation of insulin sensitivity, and we show that, in both mice and humans, pregnancy caused remodeling of adipose tissue evidenced by altered adipocyte size, vascularization, and in vitro expansion capacity. PAPPA is known to be a metalloprotease secreted by human placenta that modulates insulin-like growth factor (IGF) bioavailability through prolteolysis of IGF binding proteins (IGFBPs) 2, 4, and 5. We demonstrate that recombinant PAPPA can stimulate ex vivo human adipose tissue expansion in an IGFBP-5- and IGF-1-dependent manner. Moreover, mice lacking PAPPA displayed impaired adipose tissue remodeling, pregnancy-induced insulin resistance, and hepatic steatosis, recapitulating multiple aspects of human GDM. In a cohort of 6361 pregnant women, concentrations of circulating PAPPA are inversely correlated with glycemia and odds of developing GDM. These data identify PAPPA and the IGF signaling pathway as necessary for the regulation of maternal adipose tissue physiology and systemic glucose homeostasis, with consequences for long-term metabolic risk and potential for therapeutic use.
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Affiliation(s)
- Raziel Rojas-Rodriguez
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA.,Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Rachel Ziegler
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Tiffany DeSouza
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Sana Majid
- Clinical Translational Research Pathway, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Aylin S Madore
- Departments of Obstetrics and Gynecology, University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester, MA 01605, USA
| | - Nili Amir
- Departments of Obstetrics and Gynecology, University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester, MA 01605, USA
| | - Veronica A Pace
- Clinical Translational Research Pathway, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Daniel Nachreiner
- Clinical Translational Research Pathway, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - David Alfego
- Division of Data Sciences and Technology, IT, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Jomol Mathew
- Division of Data Sciences and Technology, IT, University of Massachusetts Medical School, Worcester, MA 01605, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Katherine Leung
- Departments of Obstetrics and Gynecology, University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester, MA 01605, USA
| | - Tiffany A Moore Simas
- Departments of Obstetrics and Gynecology, University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester, MA 01605, USA
| | - Silvia Corvera
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA.
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14
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Sapantzoglou I, Gallardo Arozena M, Dragoi V, Akolekar R, Nicolaides KH, Syngelaki A. Fetal fraction of cell free DNA in screening for hypertensive disorders at 11-13 weeks. J Matern Fetal Neonatal Med 2021; 35:5363-5368. [PMID: 33517808 DOI: 10.1080/14767058.2021.1879043] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate whether first-trimester maternal plasma fetal fraction is altered in women that subsequently develop preeclampsia (PE) or gestational hypertension (GH) and to examine its potential value in improving the performance of screening for PE and GH by maternal factors and maternal serum pregnancy associated plasma protein-A (PAPP-A), mean arterial pressure (MAP) and uterine artery pulsatility index (UtA-PI). METHODS The study population of 10,131 pregnancies undergoing cell free fetal DNA testing at 11-13 weeks' gestation included 91 (0.9%) cases with preterm-PE, 222 (2.2%) cases with term-PE, 360 (3.6%) with GH and 9,458 (93.4%) cases unaffected by hypertensive disorders. Maternal plasma fetal fraction levels were expressed as multiples of the median (MoM) after adjustment for maternal factors and crown-rump length. The performance of screening for preterm-PE, term PE and GH by maternal factors and MoM values of fetal fraction, PAPP-A, UtA-PI and MAP was evaluated by receiver operating characteristic (ROC) curves. RESULTS The median fetal fraction MoM was significantly lower in the preterm-PE (0.825; IQR 0.689-1.115 MoM, p < .001), term-PE (0.946; IQR 0.728-1.211 MoM, p = .028) and GH (0.928; IQR 0.711-1.182 MoM, p < .001) groups than in the unaffected group (1.002; IQR 0.785-1.251 MoM). However, the performance of screening for PE or GH by maternal factors alone or by maternal factors and PAPP-A, UtA-PI and MAP was not significantly improved by the addition of fetal fraction. CONCLUSIONS First trimester maternal plasma fetal fraction is not useful in screening for hypertensive disorders of pregnancy.
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Affiliation(s)
- Ioakeim Sapantzoglou
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Margarita Gallardo Arozena
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Vlad Dragoi
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Ranjit Akolekar
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
| | - Kypros H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Argyro Syngelaki
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
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15
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Correlation of PAPP-A values with maternal characteristics, biochemical and ultrasonographic markers of pregrancy. MARMARA MEDICAL JOURNAL 2021. [DOI: 10.5472/marumj.866601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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16
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Ortega MA, Fraile-Martínez O, Saez MA, Álvarez-Mon MA, Gómez-Lahoz AM, Bravo C, Luis JADL, Sainz F, Coca S, Asúnsolo Á, Monserrat J, Guijarro LG, Álvarez-Mon M, Bujan J, García-Honduvilla N. Abnormal proinflammatory and stressor environmental with increased the regulatory cellular IGF-1/PAPP-A/STC and Wnt-1/β-Catenin canonical pathway in placenta of women with Chronic venous Disease during Pregnancy. Int J Med Sci 2021; 18:2814-2827. [PMID: 34220309 PMCID: PMC8241785 DOI: 10.7150/ijms.58992] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/14/2021] [Indexed: 12/12/2022] Open
Abstract
Lower limbs venous insufficiency refers to a wide variety of venous disorders grouped by the term of chronic venous disease (CVD). Hemodynamic and hormonal changes related to pregnancy period, may promote the development of CVD affecting approximately 1 in 3 women. It has been shown that the presence of this condition is associated with damage and placental suffering. Thus, taking IGF-1/PAPP-A/STC-2, inflammatory cytokines production, PI3K/Akt and Wnt/ β-catenin pathways as a part of the alterations that occurs in the placenta due to CVD, the aim of this study will be to examine the main components of these pathways. Genic and protein expression of PAPP-A, STC-2, IGF-1, IRS-4 Wnt-1, β-catenin, c-myc, Cyclin D1, IL-4/IL-6 and PI3K/Akt/mTOR pathway will be analysed through RT-qPCR and immunohistochemical techniques in women with CVD (n=62) and pregnant women without this condition (HC) (n=52). PAPP-A, IGF-1, IL-4, IL-6, IRS-4, PI3K, Akt, mTOR, Wnt-1, β-catenin, c-myc and Cyclin D1 expression were found to be increased in women with CVD, whereas STC-2 were decreased in this group, compared to non-affected women. Our study has demonstrated that IGF-1/PAPP-A/STC-2 axis, PI3K/Akt and Wnt/β-catenin pathways, along with c-myc, Cyclin D1 and inflammatory cytokines are altered in placenta women with CVD. These results extent the knowledge that CVD is associated to a placenta damage with abnormal tissue environment and cellular regulation.
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Affiliation(s)
- Miguel A Ortega
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain.,Cancer Registry and Pathology Department, Hospital Universitario Principe de Asturias, 28806 Alcalá de Henares, Spain.,University Center for the Defense of Madrid (CUD-ACD), 28047 Madrid, Spain
| | - Oscar Fraile-Martínez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Miguel A Saez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain.,Pathological Anatomy Service, Central University Hospital of Defence-UAH Madrid, 28801 Alcalá de Henares, Madrid, Spain
| | - Miguel A Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Ana M Gómez-Lahoz
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Coral Bravo
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain.,Service of Gynecology and Obstetrics, Central University Hospital of Defense-UAH, Madrid, Spain
| | - Juan A De León Luis
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain.,Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, Madrid 28009, Spain.,Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Felipe Sainz
- Angiology and Vascular Surgery Unit, Central University Hospital of Defense-UAH, Madrid, Spain.,Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain
| | - Santiago Coca
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain.,University Center for the Defense of Madrid (CUD-ACD), 28047 Madrid, Spain
| | - Ángel Asúnsolo
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain.,Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain
| | - Jorge Monserrat
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Luis G Guijarro
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain.,Unit of Biochemistry and Molecular Biology (CIBEREHD), Department of System Biology, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Melchor Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain.,University Center for the Defense of Madrid (CUD-ACD), 28047 Madrid, Spain.,Immune System Diseases-Rheumatology, Oncology Service an Internal Medicine, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcalá de Henares, Spain
| | - Julia Bujan
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain.,University Center for the Defense of Madrid (CUD-ACD), 28047 Madrid, Spain
| | - Natalio García-Honduvilla
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain.,Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain.,University Center for the Defense of Madrid (CUD-ACD), 28047 Madrid, Spain
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17
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Lin TY, Huang HY, Chan KS, Chen YT, Chu FC, Shaw SW. Current update of first trimester preeclampsia screening in Asia. J Obstet Gynaecol Res 2020; 47:26-33. [PMID: 33063401 DOI: 10.1111/jog.14524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 08/31/2020] [Accepted: 09/28/2020] [Indexed: 11/30/2022]
Abstract
In consideration of high prevalence of preeclampsia, enormous studies attempted to look for strategies in early gestation. Hence, a powerful screening should be built up in first trimester. Then, Aspirin could be administrated for proper prevention. The objective of this article is reviewing the screening for preeclampsia in first trimester recently. To identify the high-risk group precisely, an effective model should be recommended to Asian population. Articles related to first trimester screening of PE in Asia from databases of PubMed, ScienceDirect and Scopus were searched for this narrative review. The criteria included randomized clinical trials, observational prospective and retrospective cohort studies, case-control studies, systematic review and meta-analysis and professional review articles. Screening models combining maternal factors, biophysical factors, ultrasound studies and biochemical factors achieved high predictive performance of preeclampsia. In Asia, the detection rate of the Fetal Medicine Foundation is superior to those of the American College of Obstetricians and Gynecologists and the National Institute for Health and Care Excellence. Consequently, this effective model from the Fetal Medicine Foundation should be continuously used for screening in first trimester for the Asian.
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Affiliation(s)
- Tzu-Yi Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Yu Huang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Kok-Seong Chan
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Yen-Tin Chen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Fu-Chieh Chu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Steven W Shaw
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan.,Prenatal Cell and Gene Therapy Group, Institute for Women's Health University College London, London, UK
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18
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Parisi F, Savasi VM, di Bartolo I, Mandia L, Cetin I. Associations between First Trimester Maternal Nutritional Score, Early Markers of Placental Function, and Pregnancy Outcome. Nutrients 2020; 12:nu12061799. [PMID: 32560356 PMCID: PMC7353423 DOI: 10.3390/nu12061799] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 02/05/2023] Open
Abstract
This study investigated the associations between maternal adherence to a healthy diet, first trimester placental markers, and pregnancy outcome. Singleton spontaneous pregnancies were enrolled at 11+0-13+6 gestational weeks in a prospective cohort study. A nutritional score (0-10) measuring the adherence to a healthy diet was calculated. A transabdominal ultrasound scan for placental marker assessment was performed (uterine artery (UtA) doppler, placental volume). Biochemical placental markers were recorded (Pregnancy Associated Plasma Protein A (PAPP-A), free β- Human Chorionic Gonadotropin (HCG)). Birth outcomes were obtained from medical records. Associations between the maternal nutritional score, first trimester placental markers, and pregnancy outcome were investigated by using multi-adjusted general linear models. In total, 112 pregnancies were enrolled with a median nutritional score of 7 (range 3-10). Median gestational age at birth was 277 days (range 203-296). The nutritional score was positively associated with PAPP-A concentrations, whereas a negative association was detected with the UtA mean pulsatility index and placental volume. A positive association was detected between nutritional score and gestational age at birth. This study demonstrates that a first trimester nutritional score as a measure of adherence to a healthy diet is significantly associated with early biochemical and ultrasound markers of placental development, with further association with gestational age at birth.
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Affiliation(s)
- Francesca Parisi
- Department of Woman, Child and Neonate, Buzzi Children Hospital, ASST Fatebenefratelli Sacco, 20154 Milan, Italy; (I.d.B.); (I.C.)
- Correspondence: ; Tel.: +39-02-6363-5369
| | - Valeria M. Savasi
- Department of Woman, Child and Neonate, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, 20154 Milan, Italy; (V.M.S.); (L.M.)
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy
| | - Ilenia di Bartolo
- Department of Woman, Child and Neonate, Buzzi Children Hospital, ASST Fatebenefratelli Sacco, 20154 Milan, Italy; (I.d.B.); (I.C.)
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy
| | - Luca Mandia
- Department of Woman, Child and Neonate, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, 20154 Milan, Italy; (V.M.S.); (L.M.)
| | - Irene Cetin
- Department of Woman, Child and Neonate, Buzzi Children Hospital, ASST Fatebenefratelli Sacco, 20154 Milan, Italy; (I.d.B.); (I.C.)
- Department of Woman, Child and Neonate, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, 20154 Milan, Italy; (V.M.S.); (L.M.)
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20122 Milan, Italy
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19
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Fruscalzo A, Cividino A, Rossetti E, Maurigh A, Londero AP, Driul L. First trimester PAPP-A serum levels and long-term metabolic outcome of mothers and their offspring. Sci Rep 2020; 10:5131. [PMID: 32198414 PMCID: PMC7083850 DOI: 10.1038/s41598-020-61830-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 02/26/2020] [Indexed: 11/18/2022] Open
Abstract
Low maternal serum levels of pregnancy associated plasma protein A (PAPP-A) are known to be associated with the development of pregnancy-related complications like small for gestational age infants, intrauterine fetal demise, gestational diabetes and preeclampsia. The study aims to find possible long-term correlations with the development of metabolic and cardiovascular complications in the mothers and their progeny in later life. This is a retrospective cohort study conducted on consecutive unselected women screened for chromosomal anomalies in the first trimester of pregnancy between 2004 and 2010. PAPP-A values as well as clinical data collected at childbirth were considered. A maternal and neonatal follow-up was performed through a telephone interview with the mother during 2015. The body-mass-index and the presence of cardiovascular diseases, dyslipidaemia and diabetes mellitus were evaluated. The analysis included 988 patients. The median time of follow-up was 7 years (IQR 6-9). Lower first trimester maternal blood PAPP-A quartiles were associated with small stature of the offspring (z-score 1st-2nd quartile 0.37 IQR -0.42 and 1.17 vs 3rd-4th quartile 0.67 IQR -0.17 and 1.36, p < 0.05). Furthermore, low first trimester PAPP-A in pregnancy without other gestations following the index one, in Kaplan-Meier analysis was associated to a significant increase of hypoglycemic agents use at 7 and 10 years (respectively 1.12% CI.95 0-2.38% and 5.45% CI.95 0-10.82%) compared to the control group of high first trimester PAPP-A values (0% CI.95 0-0%) (p < 0.05). Low PAPP-A serum levels in the first trimester of pregnancy are associated with short stature in offspring and de-novo development of maternal diabetes mellitus in later life.
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Affiliation(s)
- Arrigo Fruscalzo
- Frauenklinik, Christophorus-Kliniken, Coesfeld, 48653, Germany
- Clinic of Obstetrics and Gynecology, University of Münster, Münster, 48149, Germany
| | - Adriana Cividino
- Clinic of Obstetrics and Gynecology, Ostalb-Klinikum Aalen, Aalen, 73430, Germany
| | - Emma Rossetti
- Clinic of Obstetrics and Gynecology, DAME, University of Udine, ASUI - Presidio Ospedaliero Universitario "SM della Misericordia", Udine, 33100, Italy
| | - Alessia Maurigh
- Azienda Sanitaria Universitaria Integrata di Udine, Udine, 33100, Italy
| | - Ambrogio P Londero
- Clinic of Obstetrics and Gynecology, DAME, University of Udine, ASUI - Presidio Ospedaliero Universitario "SM della Misericordia", Udine, 33100, Italy.
| | - Lorenza Driul
- Clinic of Obstetrics and Gynecology, DAME, University of Udine, ASUI - Presidio Ospedaliero Universitario "SM della Misericordia", Udine, 33100, Italy
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20
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Poon LC, Shennan A, Hyett JA, Kapur A, Hadar E, Divakar H, McAuliffe F, da Silva Costa F, von Dadelszen P, McIntyre HD, Kihara AB, Di Renzo GC, Romero R, D'Alton M, Berghella V, Nicolaides KH, Hod M. The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention. Int J Gynaecol Obstet 2019; 145 Suppl 1:1-33. [PMID: 31111484 DOI: 10.1002/ijgo.12802] [Citation(s) in RCA: 468] [Impact Index Per Article: 93.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pre‐eclampsia (PE) is a multisystem disorder that typically affects 2%–5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Globally, 76 000 women and 500 000 babies die each year from this disorder. Furthermore, women in low‐resource countries are at a higher risk of developing PE compared with those in high‐resource countries.
Although a complete understanding of the pathogenesis of PE remains unclear, the current theory suggests a two‐stage process. The first stage is caused by shallow invasion of the trophoblast, resulting in inadequate remodeling of the spiral arteries. This is presumed to lead to the second stage, which involves the maternal response to endothelial dysfunction and imbalance between angiogenic and antiangiogenic factors, resulting in the clinical features of the disorder.
Accurate prediction and uniform prevention continue to elude us. The quest to effectively predict PE in the first trimester of pregnancy is fueled by the desire to identify women who are at high risk of developing PE, so that necessary measures can be initiated early enough to improve placentation and thus prevent or at least reduce the frequency of its occurrence. Furthermore, identification of an “at risk” group will allow tailored prenatal surveillance to anticipate and recognize the onset of the clinical syndrome and manage it promptly.
PE has been previously defined as the onset of hypertension accompanied by significant proteinuria after 20 weeks of gestation. Recently, the definition of PE has been broadened. Now the internationally agreed definition of PE is the one proposed by the International Society for the Study of Hypertension in Pregnancy (ISSHP).
According to the ISSHP, PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women and is accompanied by one or more of the following new‐onset conditions at or after 20 weeks of gestation:
1.Proteinuria (i.e. ≥30 mg/mol protein:creatinine ratio; ≥300 mg/24 hour; or ≥2 + dipstick);
2.Evidence of other maternal organ dysfunction, including: acute kidney injury (creatinine ≥90 μmol/L; 1 mg/dL); liver involvement (elevated transaminases, e.g. alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain; neurological complications (e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, and persistent visual scotomata); or hematological complications (thrombocytopenia–platelet count <150 000/μL, disseminated intravascular coagulation, hemolysis); or
3.Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth).
It is well established that a number of maternal risk factors are associated with the development of PE: advanced maternal age; nulliparity; previous history of PE; short and long interpregnancy interval; use of assisted reproductive technologies; family history of PE; obesity; Afro‐Caribbean and South Asian racial origin; co‐morbid medical conditions including hyperglycemia in pregnancy; pre‐existing chronic hypertension; renal disease; and autoimmune diseases, such as systemic lupus erythematosus and antiphospholipid syndrome. These risk factors have been described by various professional organizations for the identification of women at risk of PE; however, this approach to screening is inadequate for effective prediction of PE.
PE can be subclassified into:
1.Early‐onset PE (with delivery at <34+0 weeks of gestation);
2.Preterm PE (with delivery at <37+0 weeks of gestation);
3.Late‐onset PE (with delivery at ≥34+0 weeks of gestation);
4.Term PE (with delivery at ≥37+0 weeks of gestation).
These subclassifications are not mutually exclusive. Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal and perinatal morbidity and mortality.
Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer. These risks include progression to eclampsia, development of placental abruption and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. On the other hand, preterm delivery is associated with higher infant mortality rates and increased morbidity resulting from small for gestational age (SGA), thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy, and an increased risk of various chronic diseases in adult life, particularly type 2 diabetes, cardiovascular disease, and obesity. Women who have experienced PE may also face additional health problems in later life, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke, renal impairment, metabolic syndrome, and diabetes. The life expectancy of women who developed preterm PE is reduced on average by 10 years. There is also significant impact on the infants in the long term, such as increased risks of insulin resistance, diabetes mellitus, coronary artery disease, and hypertension in infants born to pre‐eclamptic women.
The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to discuss and evaluate current knowledge on PE and develop a document to frame the issues and suggest key actions to address the health burden posed by PE.
FIGO's objectives, as outlined in this document, are: (1) To raise awareness of the links between PE and poor maternal and perinatal outcomes, as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) To create a consensus document that provides guidance for the first‐trimester screening and prevention of preterm PE, and to disseminate and encourage its use.
Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of pre‐eclampsia in singleton pregnancy.1
It provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap.
To deal with the issue of PE, FIGO recommends the following:
Public health focus: There should be greater international attention given to PE and to the links between maternal health and noncommunicable diseases (NCDs) on the Sustainable Developmental Goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age should be prioritized. Greater efforts are required to raise awareness of the benefits of early prenatal visits targeted at reproductive‐aged women, particularly in low‐resource countries.
Universal screening: All pregnant women should be screened for preterm PE during early pregnancy by the first‐trimester combined test with maternal risk factors and biomarkers as a one‐step procedure. The risk calculator is available free of charge at https://fetalmedicine.org/research/assess/preeclampsia. FIGO encourages all countries and its member associations to adopt and promote strategies to ensure this. The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI). Where it is not possible to measure PLGF and/or UTPI, the baseline screening test should be a combination of maternal risk factors with MAP, and not maternal risk factors alone. If maternal serum pregnancy‐associated plasma protein A (PAPP‐A) is measured for routine first‐trimester screening for fetal aneuploidies, the result can be included for PE risk assessment. Variations to the full combined test would lead to a reduction in the performance screening. A woman is considered high risk when the risk is 1 in 100 or more based on the first‐trimester combined test with maternal risk factors, MAP, PLGF, and UTPI.
Contingent screening: Where resources are limited, routine screening for preterm PE by maternal factors and MAP in all pregnancies and reserving measurements of PLGF and UTPI for a subgroup of the population (selected on the basis of the risk derived from screening by maternal factors and MAP) can be considered.
Prophylactic measures: Following first‐trimester screening for preterm PE, women identified at high risk should receive aspirin prophylaxis commencing at 11–14+6 weeks of gestation at a dose of ~150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed. Low‐dose aspirin should not be prescribed to all pregnant women. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5–2 g elemental calcium/d) may reduce the burden of both early‐ and late‐onset PE.
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Affiliation(s)
- Liona C Poon
- Department of Obstetrics and Gynecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Andrew Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jonathan A Hyett
- Discipline of Obstetrics, Gynecology and Neonatology, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Anil Kapur
- World Diabetes Foundation, Bagsvaerd, Denmark
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Fionnuala McAuliffe
- Department of Obstetrics and Gynecology, The National Maternity Hospital, Dublin, Ireland
| | - Fabricio da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Anne B Kihara
- African Federation of Obstetrics and Gynaecology, Khartoum, Sudan
| | - Gian Carlo Di Renzo
- Center of Perinatal and Reproductive Medicine, Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, Detroit, MI, USA
| | - Mary D'Alton
- Society for Maternal-Fetal Medicine, Washington, DC, USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Kypros H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital London, London, UK
| | - Moshe Hod
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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21
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Tan MY, Syngelaki A, Poon LC, Rolnik DL, O'Gorman N, Delgado JL, Akolekar R, Konstantinidou L, Tsavdaridou M, Galeva S, Ajdacka U, Molina FS, Persico N, Jani JC, Plasencia W, Greco E, Papaioannou G, Wright A, Wright D, Nicolaides KH. Screening for pre-eclampsia by maternal factors and biomarkers at 11-13 weeks' gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:186-195. [PMID: 29896812 DOI: 10.1002/uog.19112] [Citation(s) in RCA: 199] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 05/04/2018] [Indexed: 05/07/2023]
Abstract
OBJECTIVE To examine the performance of screening for early, preterm and term pre-eclampsia (PE) at 11-13 weeks' gestation by maternal factors and combinations of mean arterial pressure (MAP), uterine artery (UtA) pulsatility index (PI), serum placental growth factor (PlGF) and serum pregnancy-associated plasma protein-A (PAPP-A). METHODS The data for this study were derived from three previously reported prospective non-intervention screening studies at 11 + 0 to 13 + 6 weeks' gestation in a combined total of 61 174 singleton pregnancies, including 1770 (2.9%) that developed PE. Bayes' theorem was used to combine the prior distribution of gestational age at delivery with PE, obtained from maternal characteristics, with various combinations of biomarker multiples of the median (MoM) values to derive patient-specific risks of delivery with PE at < 37 weeks' gestation. The performance of such screening was estimated. RESULTS In pregnancies that developed PE, compared to those without PE, the MoM values of UtA-PI and MAP were increased and those of PAPP-A and PlGF were decreased, and the deviation from normal was greater for early than late PE for all four biomarkers. Combined screening by maternal factors, UtA-PI, MAP and PlGF predicted 90% of early PE, 75% of preterm PE and 41% of term PE, at a screen-positive rate of 10%; inclusion of PAPP-A did not improve the performance of screening. The performance of screening depended on the racial origin of the women; on screening by a combination of maternal factors, MAP, UtA-PI and PlGF and using a risk cut-off of 1 in 100 for PE at < 37 weeks in Caucasian women, the screen-positive rate was 10% and detection rates for early, preterm and term PE were 88%, 69% and 40%, respectively. With the same method of screening and risk cut-off in women of Afro-Caribbean racial origin, the screen-positive rate was 34% and detection rates for early, preterm and term PE were 100%, 92% and 75%, respectively. CONCLUSION Screening by maternal factors and biomarkers at 11-13 weeks' gestation can identify a high proportion of pregnancies that develop early and preterm PE. © 2018 Crown copyright. Ultrasound in Obstetrics & Gynecology © 2018 ISUOG.
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Affiliation(s)
- M Y Tan
- King's College Hospital, London, UK
- King's College London, London, UK
| | | | - L C Poon
- King's College Hospital, London, UK
- King's College London, London, UK
| | | | | | - J L Delgado
- Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - R Akolekar
- Medway Maritime Hospital, Gillingham, UK
| | | | | | - S Galeva
- University Hospital Lewisham, London, UK
| | - U Ajdacka
- Southend University Hospital, Essex, UK
| | - F S Molina
- Hospital Universitario San Cecilio, Granada, Spain
| | - N Persico
- Ospedale Maggiore Policlinico, Milan, Italy
| | - J C Jani
- University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - W Plasencia
- Hospiten Group, Tenerife, Canary Islands, Spain
| | - E Greco
- Royal London Hospital, London, UK
| | | | - A Wright
- University of Exeter, Exeter, UK
| | - D Wright
- University of Exeter, Exeter, UK
| | - K H Nicolaides
- King's College Hospital, London, UK
- King's College London, London, UK
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Poon LC, Rolnik DL, Tan MY, Delgado JL, Tsokaki T, Akolekar R, Singh M, Andrade W, Efeturk T, Jani JC, Plasencia W, Papaioannou G, Blazquez AR, Carbone IF, Wright D, Nicolaides KH. ASPRE trial: incidence of preterm pre-eclampsia in patients fulfilling ACOG and NICE criteria according to risk by FMF algorithm. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:738-742. [PMID: 29380918 DOI: 10.1002/uog.19019] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/23/2018] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To report the incidence of preterm pre-eclampsia (PE) in women who are screen positive according to the criteria of the National Institute for Health and Care Excellence (NICE) and the American College of Obstetricians and Gynecologists (ACOG), and compare the incidence with that in those who are screen positive or screen negative by The Fetal Medicine Foundation (FMF) algorithm. METHODS This was a secondary analysis of data from the ASPRE study. The study population consisted of women with singleton pregnancy who underwent prospective screening for preterm PE by means of the FMF algorithm, which combines maternal factors and biomarkers at 11-13 weeks' gestation. The incidence of preterm PE in women fulfilling the NICE and ACOG criteria was estimated; in these patients the incidence of preterm PE was then calculated in those who were screen negative relative to those who were screen positive by the FMF algorithm. RESULTS A total of 34 573 women with singleton pregnancy delivering at ≥ 24 weeks' gestation underwent prospective screening for preterm PE, of which 239 (0.7%) cases developed preterm PE. At least one of the ACOG criteria was fulfilled in 22 287 (64.5%) pregnancies and the incidence of preterm PE was 0.97% (95% CI, 0.85-1.11%); in the subgroup that was screen positive by the FMF algorithm the incidence of preterm PE was 4.80% (95% CI, 4.14-5.55%), and in those that were screen negative it was 0.25% (95% CI, 0.18-0.33%), with a relative incidence in FMF screen negative to FMF screen positive of 0.051 (95% CI, 0.037-0.071). In 1392 (4.0%) pregnancies, at least one of the NICE high-risk criteria was fulfilled, and in this group the incidence of preterm PE was 5.17% (95% CI, 4.13-6.46%); in the subgroups of screen positive and screen negative by the FMF algorithm, the incidence of preterm PE was 8.71% (95% CI, 6.93-10.89%) and 0.65% (95% CI, 0.25-1.67%), respectively, and the relative incidence was 0.075 (95% CI, 0.028-0.205). In 2360 (6.8%) pregnancies fulfilling at least two of the NICE moderate-risk criteria, the incidence of preterm PE was 1.74% (95% CI, 1.28-2.35%); in the subgroups of screen positive and screen negative by the FMF algorithm the incidence was 4.91% (95% CI, 3.54-6.79%) and 0.42% (95% CI, 0.20-0.86%), respectively, and the relative incidence was 0.085 (95% CI, 0.038-0.192). CONCLUSION In women who are screen positive for preterm PE by the ACOG or NICE criteria but screen negative by the FMF algorithm, the risk of preterm PE is reduced to within or below background levels. The results provide further evidence to support the personalized risk-based screening method that combines maternal factors and biomarkers. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L C Poon
- King's College London, London, UK
- Chinese University of Hong Kong, Hong Kong SAR
| | | | - M Y Tan
- King's College Hospital, London, UK
- Lewisham University Hospital, London, UK
| | - J L Delgado
- Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - T Tsokaki
- King's College Hospital, London, UK
- North Middlesex University Hospital, London, UK
| | - R Akolekar
- King's College Hospital, London, UK
- Medway Maritime Hospital, Gillingham, UK
| | - M Singh
- King's College Hospital, London, UK
- Southend University Hospital, Essex, UK
| | | | - T Efeturk
- King's College Hospital, London, UK
- Homerton University Hospital, London, UK
| | - J C Jani
- University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - W Plasencia
- Hospiten Group, Tenerife, Canary Islands, Spain
| | | | - A R Blazquez
- Hospital Universitario San Cecilio, Granada, Spain
| | | | - D Wright
- University of Exeter, Exeter, UK
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Pregnancy-associated diamine oxidase originates from extravillous trophoblasts and is decreased in early-onset preeclampsia. Sci Rep 2018; 8:6342. [PMID: 29679053 PMCID: PMC5910386 DOI: 10.1038/s41598-018-24652-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 04/09/2018] [Indexed: 11/08/2022] Open
Abstract
Human extravillous trophoblast (EVT) invasion of the pregnant uterus constitutes a pivotal event for the establishment of the maternal-fetal interface. Compromised EVT function manifesting in inadequate arterial remodeling is associated with the severe pregnancy disorder early-onset preeclampsia (eoPE). Recent studies suggest that EVTs invade the entire uterine vasculature including arteries, veins and lymphatics in the first trimester of pregnancy. We therefore hypothesized that EVT-derived factors accumulate in the circulation of pregnant women early in gestation and may serve to predict eoPE. In contrast to published literature, we demonstrate that placenta-associated diamine oxidase (DAO) is not expressed by maternal decidual cells but solely by EVTs, especially when in close proximity to decidual vessels. Cultures of primary EVTs express and secret large amounts of bioactive DAO. ELISA measurements indicate a pregnancy-specific rise in maternal DAO plasma levels around gestational week (GW) 7 coinciding with vascular invasion of EVTs. Strikingly, DAO levels from eoPE cases were significantly lower (40%) compared to controls in the first trimester of pregnancy but revealed no difference at mid gestation. Furthermore, DAO-containing pregnancy plasma rapidly inactivates pathophysiologically relevant histamine levels. This study represents the first proof of concept suggesting EVT-specific signatures as diagnostic targets for the prediction of eoPE.
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Antwi E, Klipstein-Grobusch K, Browne JL, Schielen PC, Koram KA, Agyepong IA, Grobbee DE. Improved prediction of gestational hypertension by inclusion of placental growth factor and pregnancy associated plasma protein-a in a sample of Ghanaian women. Reprod Health 2018; 15:56. [PMID: 29587776 PMCID: PMC5870183 DOI: 10.1186/s12978-018-0492-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/09/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND We assessed whether adding the biomarkers Pregnancy Associated Plasma Protein-A (PAPP-A) and Placental Growth Factor (PlGF) to maternal clinical characteristics improved the prediction of a previously developed model for gestational hypertension in a cohort of Ghanaian pregnant women. METHODS This study was nested in a prospective cohort of 1010 pregnant women attending antenatal clinics in two public hospitals in Accra, Ghana. Pregnant women who were normotensive, at a gestational age at recruitment of between 8 and 13 weeks and provided a blood sample for biomarker analysis were eligible for inclusion. From serum, biomarkers PAPP-A and PlGF concentrations were measured by the AutoDELFIA immunoassay method and multiple of the median (MoM) values corrected for gestational age (PAPP-A and PlGF) and maternal weight (PAPP-A) were calculated. To obtain prediction models, these biomarkers were included with clinical predictors maternal weight, height, diastolic blood pressure, a previous history of gestational hypertension, history of hypertension in parents and parity in a logistic regression to obtain prediction models. The Area Under the Receiver Operating Characteristic Curve (AUC) was used to assess the predictive ability of the models. RESULTS Three hundred and seventy three women participated in this study. The area under the curve (AUC) of the model with only maternal clinical characteristics was 0.75 (0.64-0.86) and 0.89(0.73-1.00) for multiparous and primigravid women respectively. The AUCs after inclusion of both PAPP-A and PlGF were 0.82 (0.74-0.89) and 0.95 (0.87-1.00) for multiparous and primigravid women respectively. CONCLUSION Adding the biomarkers PAPP-A and PlGF to maternal characteristics to a prediction model for gestational hypertension in a cohort of Ghanaian pregnant women improved predictive ability. Further research using larger sample sizes in similar settings to validate these findings is recommended.
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Affiliation(s)
- Edward Antwi
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands. .,Ghana Health Service, P.M.B, Ministries, Accra, Greater Accra, Ghana.
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joyce L Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter C Schielen
- Center for Infectious Diseases Research, Diagnostics and Screening (IDS), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Kwadwo A Koram
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Irene A Agyepong
- Ghana Health Service, P.M.B, Ministries, Accra, Greater Accra, Ghana
| | - Diederick E Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Fantasia I, Kasapoglu D, Kasapoglu T, Syngelaki A, Akolekar R, Nicolaides KH. Fetal major cardiac defects and placental dysfunction at 11-13 weeks' gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:194-198. [PMID: 28833651 DOI: 10.1002/uog.18839] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 08/01/2017] [Accepted: 08/08/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate the relationship between fetal major cardiac defects and markers of placental perfusion and function. METHODS This was a prospective screening study in singleton pregnancies at 11-13 weeks' gestation. Uterine artery pulsatility index (UtA-PI), serum pregnancy-associated plasma protein-A (PAPP-A) and placental growth factor (PlGF) were measured and the values were converted into multiples of the normal median (MoM). Median MoM values in fetuses with isolated major cardiac defects were compared with those in fetuses without major defects. RESULTS The 50 094 singleton pregnancies fulfilling the entry criteria included 49 898 pregnancies with normal cardiac anatomy and 196 (0.39%) with major congenital cardiac defects: 73 (37.2%) with conotruncal defects, 63 (32.1%) with left ventricular outflow tract defects and 60 (30.6%) with valvular defects. In the group with cardiac defects, compared with controls, there was lower median PAPP-A MoM (0.81 vs 1.00, P < 0.0001) and PlGF MoM (0.78 vs 1.00, P < 0.0001) but no significant difference in UtA-PI MoM (1.01 vs 1.00, P = 0.162). CONCLUSION In pregnancies with isolated fetal major cardiac defects, there is evidence of placental dysfunction in the absence of impaired placental perfusion. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Fantasia
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - D Kasapoglu
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - T Kasapoglu
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Syngelaki
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - R Akolekar
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
- Department of Fetal Medicine, Medway Maritime Hospital, Gillingham, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Aspirin for Evidence-Based Preeclampsia Prevention trial: influence of compliance on beneficial effect of aspirin in prevention of preterm preeclampsia. Am J Obstet Gynecol 2017; 217:685.e1-685.e5. [PMID: 28888591 DOI: 10.1016/j.ajog.2017.08.110] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/28/2017] [Accepted: 08/31/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Aspirin for Evidence-Based Preeclampsia Prevention trial was a multicenter study in women with singleton pregnancies. Screening was carried out at 11-13 weeks' gestation with an algorithm that combines maternal factors and biomarkers (mean arterial pressure, uterine artery pulsatility index, and maternal serum pregnancy-associated plasma protein A and placental growth factor). Those with an estimated risk for preterm preeclampsia of >1 in 100 were invited to participate in a double-blind trial of aspirin (150 mg/d) vs placebo from 11-14 until 36 weeks' gestation. Preterm preeclampsia with delivery at <37 weeks' gestation, which was the primary outcome, occurred in 1.6% (13/798) participants in the aspirin group, as compared with 4.3% (35/822) in the placebo group (odds ratio in the aspirin group, 0.38; 95% confidence interval, 0.20 to 0.74). OBJECTIVE We sought to examine the influence of compliance on the beneficial effect of aspirin in prevention of preterm preeclampsia in the Aspirin for Evidence-Based Preeclampsia Prevention trial. STUDY DESIGN This was a secondary analysis of data from the trial. The proportion of prescribed tablets taken was used as an overall measure of compliance. Logistic regression analysis was used to estimate the effect of aspirin on the incidence of preterm preeclampsia according to compliance of <90% and ≥90%, after adjustment for the estimated risk of preterm preeclampsia at screening and the participating center. The choice of cut-off of 90% was based on an exploratory analysis of the treatment effect. Logistic regression analysis was used to investigate predictors of compliance ≥90% among maternal characteristics and medical history. RESULTS Preterm preeclampsia occurred in 5/555 (0.9%) participants in the aspirin group with compliance ≥90%, in 8/243 (3.3%) of participants in the aspirin group with compliance <90%, in 22/588 (3.7%) of participants in the placebo group with compliance ≥90%, and in 13/234 (5.6%) of participants in the placebo group with compliance <90%. The odds ratio in the aspirin group for preterm preeclampsia was 0.24 (95% confidence interval, 0.09-0.65) for compliance ≥90% and 0.59 (95% confidence interval, 0.23-1.53) for compliance <90%. Compliance was positively associated with family history of preeclampsia and negatively associated with smoking, maternal age <25 years, Afro-Caribbean and South Asian racial origin, and history of preeclampsia in a previous pregnancy. CONCLUSION The beneficial effect of aspirin in the prevention of preterm preeclampsia appears to depend on compliance.
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Panaitescu AM, Akolekar R, Kametas N, Syngelaki A, Nicolaides KH. Impaired placentation in women with chronic hypertension who develop pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:496-500. [PMID: 28470791 DOI: 10.1002/uog.17517] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 04/30/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To compare the degree of impaired placentation in women with and those without chronic hypertension (CH) who develop pre-eclampsia (PE) in pregnancy. METHODS Data were derived from prospective screening for adverse pregnancy outcomes in women with singleton pregnancy attending their first routine hospital visit at 11 + 0 to 13 + 6 weeks' gestation. This visit included recording of maternal characteristics and medical history and measurement of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum pregnancy-associated plasma protein-A (PAPP-A). The measured biomarkers were converted to multiples of the median (MoM) after adjustment for pregnancy characteristics. MoM values in women with CH who developed PE (n = 283) were compared to those of women without CH who developed PE (n = 2236). RESULTS In both groups with and without CH, measurements of MAP and UtA-PI were increased, whereas those of PlGF and PAPP-A were decreased and the deviation from normal in all biomarkers decreased with advancing gestational age at delivery with PE. There was no significant difference between women with and those without CH in the slope of the regression line of log10 MoM biomarker values against gestational age at delivery with PE for any of the biomarkers. However, there was a significant difference in the intercepts and coefficients of biomarkers in the two groups; compared to those without CH, MAP MoM, PlGF MoM and PAPP-A MoM were higher and UtA-PI MoM was lower in the CH group (all P < 0.01). CONCLUSION In pregnancies that develop PE, the degree of impaired placentation, reflected in high UtA-PI and low PlGF and PAPP-A at 11-13 weeks' gestation, is less in women with CH than in those without CH. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A M Panaitescu
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - R Akolekar
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- Department of Fetal Medicine, Medway Maritime Hospital, Gillingham, Kent, UK
| | - N Kametas
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - A Syngelaki
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
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Rolnik DL, Wright D, Poon LCY, Syngelaki A, O'Gorman N, de Paco Matallana C, Akolekar R, Cicero S, Janga D, Singh M, Molina FS, Persico N, Jani JC, Plasencia W, Papaioannou G, Tenenbaum-Gavish K, Nicolaides KH. ASPRE trial: performance of screening for preterm pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:492-495. [PMID: 28741785 DOI: 10.1002/uog.18816] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/19/2017] [Indexed: 05/07/2023]
Abstract
OBJECTIVE To examine the performance of screening for preterm and term pre-eclampsia (PE) in the study population participating in the ASPRE (Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-Based Preeclampsia Prevention) trial. METHODS This was a prospective first-trimester multicenter study on screening for preterm PE in 26 941 singleton pregnancies by means of an algorithm that combines maternal factors, mean arterial pressure, uterine artery pulsatility index and maternal serum pregnancy-associated plasma protein-A and placental growth factor at 11-13 weeks' gestation. Eligible women with an estimated risk for preterm PE of > 1 in 100 were invited to participate in a double-blind trial of aspirin (150 mg per day) vs placebo from 11-14 until 36 weeks' gestation, which showed that, in the aspirin group, the incidence of preterm PE was reduced by 62%. In the screened population, the detection rates (DRs) and false-positive rates (FPRs) for delivery with PE < 37 and ≥ 37 weeks were estimated after adjustment for the effect of aspirin in those receiving this treatment. We excluded 1144 (4.2%) pregnancies because of loss to follow-up or study withdrawal (n = 716), miscarriage (n = 243) or termination (n = 185). RESULTS The study population of 25 797 pregnancies included 180 (0.7%) cases of preterm PE, 450 (1.7%) of term PE and 25 167 (97.6%) without PE. In combined first-trimester screening for preterm PE with a risk cut-off of 1 in 100, the DR was 76.7% (138/180) for preterm PE and 43.1% (194/450) for term PE, at screen-positive rate of 10.5% (2707/25 797) and FPR of 9.2% (2375/25 797). CONCLUSION The performance of screening in the ASPRE study was comparable with that of a study of approximately 60 000 singleton pregnancies used for development of the algorithm; in that study, combined screening detected 76.6% of cases of preterm PE and 38.3% of term PE at a FPR of 10%. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
| | - D Wright
- University of Exeter, Exeter, UK
| | - L C Y Poon
- King's College Hospital, London, UK
- The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | | | | | - R Akolekar
- Medway Maritime Hospital, Gillingham, Kent, UK
| | - S Cicero
- Homerton University Hospital, London, UK
| | - D Janga
- North Middlesex University Hospital, London, UK
| | - M Singh
- Southend University Hospital, Essex, UK
| | - F S Molina
- Hospital Universitario San Cecilio, Granada, Spain
| | - N Persico
- Ospedale Maggiore Policlinico, Milan, Italy
| | - J C Jani
- University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - W Plasencia
- Hospiten Group, Tenerife, Canary Islands, Spain
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Romero R, Erez O, Maymon E, Chaemsaithong P, Xu Z, Pacora P, Chaiworapongsa T, Done B, Hassan SS, Tarca AL. The maternal plasma proteome changes as a function of gestational age in normal pregnancy: a longitudinal study. Am J Obstet Gynecol 2017; 217:67.e1-67.e21. [PMID: 28263753 PMCID: PMC5813489 DOI: 10.1016/j.ajog.2017.02.037] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/10/2017] [Accepted: 02/23/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Pregnancy is accompanied by dramatic physiological changes in maternal plasma proteins. Characterization of the maternal plasma proteome in normal pregnancy is an essential step for understanding changes to predict pregnancy outcome. The objective of this study was to describe maternal plasma proteins that change in abundance with advancing gestational age and determine biological processes that are perturbed in normal pregnancy. STUDY DESIGN A longitudinal study included 43 normal pregnancies that had a term delivery of an infant who was appropriate for gestational age without maternal or neonatal complications. For each pregnancy, 3 to 6 maternal plasma samples (median, 5) were profiled to measure the abundance of 1125 proteins using multiplex assays. Linear mixed-effects models with polynomial splines were used to model protein abundance as a function of gestational age, and the significance of the association was inferred via likelihood ratio tests. Proteins considered to be significantly changed were defined as having the following: (1) >1.5-fold change between 8 and 40 weeks of gestation; and (2) a false discovery rate-adjusted value of P < .1. Gene ontology enrichment analysis was used to identify biological processes overrepresented among the proteins that changed with advancing gestation. RESULTS The following results were found: (1) Ten percent (112 of 1125) of the profiled proteins changed in abundance as a function of gestational age; (2) of the 1125 proteins analyzed, glypican-3, sialic acid-binding immunoglobulin-type lectin-6, placental growth factor, C-C motif-28, carbonic anhydrase 6, prolactin, interleukin-1 receptor 4, dual-specificity mitogen-activated protein kinase 4, and pregnancy-associated plasma protein-A had more than a 5-fold change in abundance across gestation (these 9 proteins are known to be involved in a wide range of both physiological and pathological processes, such as growth regulation, embryogenesis, angiogenesis immunoregulation, inflammation etc); and (3) biological processes associated with protein changes in normal pregnancy included defense response, defense response to bacteria, proteolysis, and leukocyte migration (false discovery rate, 10%). CONCLUSION The plasma proteome of normal pregnancy demonstrates dramatic changes in both the magnitude of changes and the fraction of the proteins involved. Such information is important to understand the physiology of pregnancy and the development of biomarkers to differentiate normal vs abnormal pregnancy and determine the response to interventions.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
| | - Offer Erez
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Eli Maymon
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Piya Chaemsaithong
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Zhonghui Xu
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI
| | - Percy Pacora
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Bogdan Done
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI
| | - Sonia S Hassan
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Adi L Tarca
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI.
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O'Gorman N, Wright D, Poon LC, Rolnik DL, Syngelaki A, Wright A, Akolekar R, Cicero S, Janga D, Jani J, Molina FS, de Paco Matallana C, Papantoniou N, Persico N, Plasencia W, Singh M, Nicolaides KH. Accuracy of competing-risks model in screening for pre-eclampsia by maternal factors and biomarkers at 11-13 weeks' gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:751-755. [PMID: 28067011 DOI: 10.1002/uog.17399] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To examine the diagnostic accuracy of a previously developed model for prediction of pre-eclampsia (PE) by a combination of maternal factors and biomarkers at 11-13 weeks' gestation. METHODS This was a prospective first-trimester multicenter study of screening for PE in 8775 singleton pregnancies. A previously published algorithm was used for the calculation of patient-specific risk of PE in each individual. The detection rates (DRs) and false-positive rates (FPRs) for delivery with PE < 32, < 37 and ≥ 37 weeks were estimated and compared with those for the dataset used for development of the algorithm. RESULTS In the study population, 239 (2.7%) cases developed PE, of which 17 (0.2%), 59 (0.7%) and 180 (2.1%) developed PE < 32, < 37 and ≥ 37 weeks, respectively. With combined screening by maternal factors, mean arterial pressure, uterine artery pulsatility index and serum placental growth factor, the DR was 100% (95% CI, 80-100%) for PE < 32 weeks, 75% (95% CI, 62-85%) for PE < 37 weeks and 43% (95% CI, 35-50%) for PE ≥ 37 weeks, at a 10% FPR. These DRs were similar to the estimated rates for the dataset used for development of the model: 89% (95% CI, 79-96%) for PE < 32 weeks, 75% (95% CI, 70-80%) for PE < 37 weeks and 47% (95% CI, 44-51%) for PE ≥ 37 weeks. CONCLUSION Assessment of a combination of maternal factors and biomarkers at 11-13 weeks provides effective first-trimester screening for preterm PE. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- N O'Gorman
- Harris Birthright Centre for Fetal Medicine, King's College Hospital, London, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - L C Poon
- Harris Birthright Centre for Fetal Medicine, King's College Hospital, London, UK
- Chinese University of Hong Kong, Hong Kong, China
| | - D L Rolnik
- Harris Birthright Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Syngelaki
- Harris Birthright Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - R Akolekar
- Harris Birthright Centre for Fetal Medicine, King's College Hospital, London, UK
- Medway Maritime Hospital, Gillingham, UK
| | - S Cicero
- Homerton University Hospital, London, UK
| | - D Janga
- North Middlesex University Hospital, London, UK
| | - J Jani
- Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - F S Molina
- Hospital Universitario San Cecilio, Granada, Spain
| | | | | | - N Persico
- Ospedale Maggiore Policlinico, Milan, Italy
| | - W Plasencia
- Hospiten Group, Tenerife, Canary Islands, Spain
| | - M Singh
- Southend University Hospital, Essex, UK
| | - K H Nicolaides
- Harris Birthright Centre for Fetal Medicine, King's College Hospital, London, UK
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Petry CJ, Ong KK, Hughes IA, Acerini CL, Frystyk J, Dunger DB. Early Pregnancy-Associated Plasma Protein A Concentrations Are Associated With Third Trimester Insulin Sensitivity. J Clin Endocrinol Metab 2017; 102:2000-2008. [PMID: 28323969 PMCID: PMC5464396 DOI: 10.1210/jc.2017-00272] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/08/2017] [Indexed: 01/04/2023]
Abstract
CONTEXT First or early second trimester pregnancy-associated plasma protein A (PAPP-A) concentrations have previously been shown to be lower in women who subsequently develop gestational diabetes mellitus (GDM) and gestational hypertension. OBJECTIVE We therefore sought to investigate why circulating PAPP-A concentrations are related to the subsequent risk of GDM and gestational hypertension. PATIENTS, DESIGN, AND SETTING We measured serum PAPP-A concentrations around week 15 of pregnancy and related these to indices derived from week 28 oral glucose tolerance tests and blood pressures across pregnancy in the Cambridge Baby Growth Study cohort. RESULTS Increased PAPP-A concentrations were associated with reduced GDM risk [odds ratio 0.623 (0.453, 0.856), P = 3.5 × 10-3, n = 777] and reduced mean arterial blood pressures (β = -0.202 to -0.177, P = 1.7 to 6.9 × 10-3, n = 347 to 355). They were also negatively associated with week 28 fasting (β = -0.149, P = 6.6 × 10-4, n = 777) and 60-minute (β = -0.188, P = 1.5 × 10-5, n = 777) oral glucose tolerance test glucose concentrations. These associations were underpinned by the strong associations between increased week 15 PAPP-A concentrations and decreased week 28 insulin resistance (homeostasis model assessment of insulin resistance: β = -0.319, P = 1.7 × 10-13, n = 768), as well as increased insulin secretion relative to insulin sensitivity (insulin disposition index: β = 0.202, P = 6.5 × 10-6, n = 731). CONCLUSIONS These results suggest that links between PAPP-A concentrations in early pregnancy and subsequent glucose concentrations and blood pressures may be mediated by changes in insulin sensitivity (and secretion).
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Affiliation(s)
- Clive J. Petry
- Department of Paediatrics, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - Ken K. Ong
- Department of Paediatrics, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - Ieuan A. Hughes
- Department of Paediatrics, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - Carlo L. Acerini
- Department of Paediatrics, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - Jan Frystyk
- Medical Research Laboratory, Department of Clinical Medicine, Aarhus University, 8000 Aarhus, Denmark
| | - David B. Dunger
- Department of Paediatrics, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
- Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
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O'Gorman N, Wright D, Poon LC, Rolnik DL, Syngelaki A, de Alvarado M, Carbone IF, Dutemeyer V, Fiolna M, Frick A, Karagiotis N, Mastrodima S, de Paco Matallana C, Papaioannou G, Pazos A, Plasencia W, Nicolaides KH. Multicenter screening for pre-eclampsia by maternal factors and biomarkers at 11-13 weeks' gestation: comparison with NICE guidelines and ACOG recommendations. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:756-760. [PMID: 28295782 DOI: 10.1002/uog.17455] [Citation(s) in RCA: 206] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 02/08/2017] [Indexed: 05/07/2023]
Abstract
OBJECTIVE To compare the performance of screening for pre-eclampsia (PE) based on risk factors from medical history, as recommended by NICE and ACOG, with the method proposed by The Fetal Medicine Foundation (FMF), which uses Bayes' theorem to combine the a-priori risk from maternal factors, derived by a multivariable logistic model, with the results of various combinations of biophysical and biochemical measurements. METHODS This was a prospective multicenter study of screening for PE in 8775 singleton pregnancies at 11-13 weeks' gestation. A previously published FMF algorithm was used for the calculation of patient-specific risk of PE in each individual. The detection rates (DRs) and false-positive rates (FPRs) for delivery with PE < 32, < 37 and ≥ 37 weeks were estimated and compared with those derived from application of NICE guidelines and ACOG recommendations. According to NICE, all high-risk pregnancies should be offered low-dose aspirin. According to ACOG, use of aspirin should be reserved for women with a history of PE in at least two previous pregnancies or PE requiring delivery < 34 weeks' gestation. RESULTS In the study population, 239 (2.7%) cases developed PE, of which 17 (0.2%), 59 (0.7%) and 180 (2.1%) developed PE < 32, < 37 and ≥ 37 weeks, respectively. Screening with use of the FMF algorithm based on a combination of maternal factors, mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF) detected 100% (95% CI, 80-100%) of PE < 32 weeks, 75% (95% CI, 62-85%) of PE < 37 weeks and 43% (95% CI, 35-50%) of PE ≥ 37 weeks, at a 10.0% FPR. Screening with use of NICE guidelines detected 41% (95% CI, 18-67%) of PE < 32 weeks, 39% (95% CI, 27-53%) of PE < 37 weeks and 34% (95% CI, 27-41%) of PE ≥ 37 weeks, at 10.2% FPR. Screening with use of ACOG recommendations detected 94% (95% CI, 71-100%) of PE < 32 weeks, 90% (95% CI, 79-96%) of PE < 37 weeks and 89% (95% CI, 84-94%) of PE ≥ 37 weeks, at 64.2% FPR. Screening based on the ACOG recommendations for use of aspirin detected 6% (95% CI, 1-27%) of PE < 32 weeks, 5% (95% CI, 2-14%) of PE < 37 weeks and 2% (95% CI, 0.3-5%) of PE ≥ 37 weeks, at 0.2% FPR. CONCLUSION Performance of screening for PE at 11-13 weeks' gestation by the FMF algorithm using a combination of maternal factors, MAP, UtA-PI and PlGF, is by far superior to the methods recommended by NICE and ACOG. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- N O'Gorman
- Harris Birthright Center for Fetal Medicine, King's College Hospital, London, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - L C Poon
- Harris Birthright Center for Fetal Medicine, King's College Hospital, London, UK
- Chinese University of Hong Kong, Hong Kong, China
| | - D L Rolnik
- Harris Birthright Center for Fetal Medicine, King's College Hospital, London, UK
| | - A Syngelaki
- Harris Birthright Center for Fetal Medicine, King's College Hospital, London, UK
| | - M de Alvarado
- Harris Birthright Center for Fetal Medicine, King's College Hospital, London, UK
- Homerton University Hospital, London, UK
| | | | - V Dutemeyer
- Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - M Fiolna
- Harris Birthright Center for Fetal Medicine, King's College Hospital, London, UK
- Medway Maritime Hospital, Gillingham, UK
| | - A Frick
- Harris Birthright Center for Fetal Medicine, King's College Hospital, London, UK
- Lewisham University Hospital, London, UK
| | - N Karagiotis
- Harris Birthright Center for Fetal Medicine, King's College Hospital, London, UK
| | - S Mastrodima
- Harris Birthright Center for Fetal Medicine, King's College Hospital, London, UK
- North Middlesex University Hospital, London, UK
| | | | | | - A Pazos
- Hospital Universitario San Cecilio, Granada, Spain
| | - W Plasencia
- Hospiten Group, Tenerife, Canary Islands, Spain
| | - K H Nicolaides
- Harris Birthright Center for Fetal Medicine, King's College Hospital, London, UK
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Vidal M, Vellvé K, González-Comadran M, Robles A, Prat M, Torné M, Carreras R, Checa MA. Perinatal outcomes in children born after fresh or frozen embryo transfer: a Catalan cohort study based on 14,262 newborns. Fertil Steril 2017; 107:940-947. [PMID: 28292612 DOI: 10.1016/j.fertnstert.2017.01.021] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/10/2017] [Accepted: 01/24/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To ascertain whether perinatal outcomes are affected by vitrification and/or controlled ovarian hyperstimulation (COH). DESIGN Register-based cohort study. SETTING Not applicable. PATIENT(S) Women undergoing in vitro fertilization (IVF) between 2008 and 2012 using autologous or donated eggs who had a singleton pregnancy delivered from the 24th week onward. INTERVENTION(S) Fresh embryo transfer (ET) or frozen-thawed ET in women undergoing IVF. MAIN OUTCOME MEASURE(S) Primary outcome birthweight, and secondary outcomes gestational age at delivery, small for gestational age, mode of delivery, and perinatal mortality. RESULT(S) In the autologous egg population, newborns from the fresh ET group had lower birthweight than the frozen-thawed ET group (3,152.9 ± 545.5g and 3,343.2 ± 532.3g, respectively), and this difference persisted even after adjusting for confounding factors, and the newborns had a higher risk of being small for gestational age (SGA). In contrast, among egg-donor recipients undergoing ET, the mean birthweight did not differ between the groups (3,165 ± 604.15 g and 3,143.60 ± 604.21g in the fresh and frozen-thawed ET groups, respectively); however, in the adjusted regression model birthweight was statistically significantly higher in the fresh ET group than the frozen-thawed ET group. The risk of SGA remained comparable between the fresh versus frozen-thawed ET groups. We observed no statistically significant differences in perinatal mortality between groups either in the autologous egg population or in the donor recipient group. CONCLUSION(S) Perinatal outcomes are negatively affected by COH and not affected by the vitrification process.
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Affiliation(s)
- Mar Vidal
- Obstetrics and Gynecology Department, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Kilian Vellvé
- Obstetrics and Gynecology Department, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mireia González-Comadran
- Obstetrics and Gynecology Department, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; GRI-BCN, Barcelona Infertility Research Group, IMIM, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | - Ana Robles
- Obstetrics and Gynecology Department, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; GRI-BCN, Barcelona Infertility Research Group, IMIM, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | - Maria Prat
- Obstetrics and Gynecology Department, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; GRI-BCN, Barcelona Infertility Research Group, IMIM, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | - Mar Torné
- Assisted Human Reproduction Registry, Department of Planning and Health Research, Department of Health, Generalitat de Catalunya, Barcelona, Spain
| | - Ramón Carreras
- Obstetrics and Gynecology Department, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miguel A Checa
- Obstetrics and Gynecology Department, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; GRI-BCN, Barcelona Infertility Research Group, IMIM, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain.
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Keikkala E, Koskinen S, Vuorela P, Laivuori H, Romppanen J, Heinonen S, Stenman UH. First trimester serum placental growth factor and hyperglycosylated human chorionic gonadotropin are associated with pre-eclampsia: a case control study. BMC Pregnancy Childbirth 2016; 16:378. [PMID: 27887594 PMCID: PMC5124279 DOI: 10.1186/s12884-016-1169-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 11/16/2016] [Indexed: 01/23/2023] Open
Abstract
Background To study whether maternal serum hyperglycosylated human chorionic gonadotropin (hCG-h) improves first trimester prediction of pre-eclampsia when combined with placental growth factor (PlGF), pregnancy-associated plasma protein-A (PAPP-A) and maternal risk factors. Methods Gestational-age-adjusted concentrations of hCG, hCG-h, PlGF and PAPP-A were analysed in serum samples by time-resolved immunofluorometric assays at 8–13 weeks of gestation. The case–control study included 98 women who developed pre-eclampsia, 25 who developed gestational hypertension, 41 normotensive women with small-for-gestational-age (SGA) infants and 177 controls. Results Of 98 women with pre-eclampsia, 24 women developed preterm pre-eclampsia (diagnosis < 37 weeks of gestation) and 13 of them had early-onset pre-eclampsia (diagnosis < 34 weeks of gestation). They had lower concentrations of PlGF, PAPP-A and proportion of hCG-h to hCG (%hCG-h) than controls. In receiver-operating characteristics (ROC) curve analysis, the area under the curve (AUC) for the combination of PlGF, PAPP-A, %hCG-h, nulliparity and mean arterial blood pressure was 0.805 (95% confidence interval, CI, 0.699–0.912) for preterm pre-eclampsia and 0.870 (95% CI 0.750–0.988) for early-onset pre-eclampsia. Without %hCG-h the AUC values were 0.756 (95% CI 0.651–0.861) and 0.810 (95% CI 0.682–0.938) respectively. For prediction of gestational hypertension, the AUC for %hCG-h was 0.708 (95% CI 0.608–0.808), but for other markers the AUC values were not significant. None of the AUC values were significant for the prediction of SGA infants in normotensive women. Conclusions First trimester maternal serum %hCG-h tended to improve prediction of preterm and early-onset pre-eclampsia when combined with PlGF, PAPP-A and maternal risk factors.
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Affiliation(s)
- Elina Keikkala
- Obstetrics and Gynecology, University of Oulu and Oulu University Hospital, Northern Ostrobothnia Hospital District, PB 23, 90029, Oulu, Finland
| | - Sini Koskinen
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, PB 700, 00029, Helsinki, Finland.
| | - Piia Vuorela
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, PB 700, 00029, Helsinki, Finland.,Obstetrics and Gynecology, Porvoo Hospital, PB 500, 06151, Porvoo, Finland
| | - Hannele Laivuori
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, PB 700, 00029, Helsinki, Finland.,Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, PB 63, 00014, Helsinki, Finland.,Institute for Molecular Medicine Finland, University of Helsinki, PB 20, 00014, Helsinki, Finland
| | - Jarkko Romppanen
- Eastern Finland Laboratory Centre, PB 1700, 70211, Kuopio, Finland
| | - Seppo Heinonen
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Biomedicum Helsinki, PB 700, 00029, Helsinki, Finland
| | - Ulf-Håkan Stenman
- Clinical Chemistry, University of Helsinki and Helsinki University Hospital, PB 700, 00029, Helsinki, Finland
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Mastrodima S, Akolekar R, Yerlikaya G, Tzelepis T, Nicolaides KH. Prediction of stillbirth from biochemical and biophysical markers at 11-13 weeks. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:613-617. [PMID: 27561595 DOI: 10.1002/uog.17289] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/09/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To develop a model for the prediction of stillbirth that is based on a combination of maternal characteristics and medical history with first-trimester biochemical and biophysical markers and to evaluate the performance of screening with this model for all stillbirths and those due to impaired placentation and unexplained causes. METHODS This was a prospective screening study of 76 897 singleton pregnancies, including 76 629 live births and 268 (0.35%) antepartum stillbirths; 157 (59%) were secondary to impaired placentation and 111 (41%) were due to other or unexplained causes. Multivariable logistic regression analysis was used to determine if there was a significant contribution to prediction of stillbirth from the maternal factor-derived a-priori risk, fetal nuchal translucency thickness, ductus venosus pulsatility index for veins (DV-PIV), uterine artery pulsatility index (UtA-PI) and maternal serum free β-human chorionic gonadotropin and pregnancy-associated plasma protein-A (PAPP-A). The significant contributors were used to derive a model for first-trimester prediction of stillbirth. RESULTS Significant contribution to prediction of stillbirth was provided by maternal factors, PAPP-A, UtA-PI and DV-PIV. A model combining these variables predicted 40% of all stillbirths and 55% of those due to impaired placentation, at a false-positive rate of 10%. Within the impaired-placentation group, the detection rate of stillbirth < 32 weeks' gestation was higher than that of stillbirth ≥ 37 weeks (64% vs 42%). CONCLUSIONS A model based on maternal factors and first-trimester biomarkers can potentially predict more than half of subsequent stillbirths that occur due to impaired placentation. The extent to which such stillbirths could be prevented remains to be determined. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S Mastrodima
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - R Akolekar
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
- Department of Fetal Medicine, Medway Maritime Hospital, Gillingham, UK
| | - G Yerlikaya
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - T Tzelepis
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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36
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Akolekar R, Machuca M, Mendes M, Paschos V, Nicolaides KH. Prediction of stillbirth from placental growth factor at 11-13 weeks. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:618-623. [PMID: 27854388 DOI: 10.1002/uog.17288] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/15/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To investigate whether the addition of maternal serum placental growth factor (PlGF) measured at 11-13 weeks' gestation improves the performance of screening for stillbirths that is achieved by a combination of maternal factors and first-trimester biomarkers such as maternal serum pregnancy-associated plasma protein-A (PAPP-A), fetal ductus venosus pulsatility index for veins (DV-PIV) and uterine artery pulsatility index (UtA-PI) and to evaluate the performance of screening with this model for all stillbirths and those due to impaired placentation and unexplained causes. METHODS This was a prospective screening study of 45 452 singleton pregnancies including 45 225 live births and 227 (0.49%) antepartum stillbirths; 131 (58%) were secondary to impaired placentation and 96 (42%) were due to other or unexplained causes. Multivariable logistic regression analysis was used to determine whether the addition of maternal serum PlGF improved the performance of screening that was achieved by a combination of maternal factors and PAPP-A, DV-PIV and UtA-PI. RESULTS Significant contribution to the prediction of stillbirth was provided by maternal factor-derived a-priori risk and multiples of the median values of PlGF, DV-PIV and UtA-PI but not of serum PAPP-A. A model combining these variables predicted 42% of all stillbirths and 61% of those due to impaired placentation, at a false-positive rate of 10%; within the impaired placentation group the detection rate of stillbirth < 32 weeks' gestation was higher than that of stillbirth ≥ 37 weeks (71% vs 46%; P = 0.031). CONCLUSIONS A high proportion of stillbirths due to impaired placentation can be identified effectively in the first trimester of pregnancy. Addition of PlGF improves the performance of screening achieved by other maternal factors and biomarkers. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Akolekar
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
- Department of Fetal Medicine, Medway Maritime Hospital, Gillingham, UK
| | - M Machuca
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
- Department of Fetal Medicine, Medway Maritime Hospital, Gillingham, UK
| | - M Mendes
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - V Paschos
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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37
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Browne JL, Klipstein-Grobusch K, Koster MPH, Ramamoorthy D, Antwi E, Belmouden I, Franx A, Grobbee DE, Schielen PCJI. Pregnancy Associated Plasma Protein-A and Placental Growth Factor in a Sub-Saharan African Population: A Nested Cross-Sectional Study. PLoS One 2016; 11:e0159592. [PMID: 27532602 PMCID: PMC4988712 DOI: 10.1371/journal.pone.0159592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/06/2016] [Indexed: 01/11/2023] Open
Abstract
Background Baseline distributions of pregnancy disorders’ biomarkers PlGF and PAPP-A levels are primarily based on Western European populations of Caucasian ethnicity. Differences in PAPP-A and PlGF concentrations by ethnicity have been observed, with increased levels in Afro-Caribbean, East Asian, and South Asian women. Baseline concentrations of sub-Saharan African women have not been evaluated. Objectives To investigate PlGF and PAPP-A in a sub-Saharan African population and assess the performance of existing reference values of PAPP-A and PlGF. Methods A nested cross-sectional study was conducted in two public hospitals in Accra, Ghana. Out of the original 1010 women enrolled in the cohort, 398 participants were eligible for inclusion with a normotensive singleton gestation and serum samples taken between 56–97 days of pregnancy. PAPP-A and PlGF concentrations were measured with an automated immunoassay. Multiple of the median (MoM) values corrected for gestation and maternal weight for PAPP-A and PlGF were calculated using reference values of a Dutch perinatal screening laboratory based on over 10.000 samples, and PlGF manufacturer reference values, respectively. Results The PAPP-A median MoM was 2.34 (interquartile range (IQR) 1.24–3.97). Median PlGF MoM was 1.25 (IQR 0.95–1.80). Median MoM values for PAPP-A and PlGF tended to be slightly different for various Ghanaian ethnic subgroups. Conclusions PAPP-A and PlGF MoM values appear to be substantially higher in a sub-Saharan African population compared to the Caucasian or Afro-Caribbean MoM values previously reported. The difference suggests the need for a specific correction factor for this population to avoid underestimation of risk for fetal aneuploidies or placental disorders when using PAPP-A and PlGF MoM for screening purposes.
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Affiliation(s)
- Joyce L. Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- * E-mail:
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maria P. H. Koster
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, The Netherlands
| | - Dhivya Ramamoorthy
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Edward Antwi
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Ghana Health Service, Greater Accra Regional Health Directorate, Accra, Ghana
| | - Idder Belmouden
- Center for Infectious Diseases Research, Diagnostics and Screening (IDS), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, The Netherlands
| | - Diederick E. Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter C. J. I. Schielen
- Center for Infectious Diseases Research, Diagnostics and Screening (IDS), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
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Wright A, Guerra L, Pellegrino M, Wright D, Nicolaides KH. Maternal serum PAPP-A and free β-hCG at 12, 22 and 32 weeks' gestation in screening for pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:762-767. [PMID: 26726121 DOI: 10.1002/uog.15849] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 11/27/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To examine the distribution of maternal serum pregnancy-associated plasma protein-A (PAPP-A) and free β-human chorionic gonadotropin (β-hCG) at 12, 22 and 32 weeks' gestation in singleton pregnancies which develop pre-eclampsia (PE) and examine the performance of these biomarkers in screening for PE. METHODS Serum PAPP-A and free β-hCG were measured in 94 989 cases at 11-13 weeks, 7597 at 19-24 weeks and 8088 at 30-34 weeks' gestation. Bayes' theorem was used to combine the a-priori risk from maternal characteristics and medical history with PAPP-A and free β-hCG. The empirical and model-based performance of screening for preterm PE requiring delivery < 37 weeks' gestation and term PE with delivery ≥ 37 weeks was estimated. RESULTS Combined screening with maternal factors and serum PAPP-A at 11-13 and 30-34 weeks and with maternal factors and serum free β-hCG at 19-24 and 30-34 weeks improved the prediction provided by maternal factors alone for preterm PE. The detection rate, at a 10% false-positive rate, for preterm PE by screening with maternal factors was about 45% which improved to 51% and 53% by combined screening with PAPP-A at 11-13 weeks and 30-34 weeks, respectively, and 55% and 54% by combined screening with free β-hCG at 19-24 weeks and 30-34 weeks, respectively. Measurement of serum PAPP-A and free β-hCG was not useful in the prediction of term PE. CONCLUSIONS Measurement of serum PAPP-A and free β-hCG could improve the prediction of preterm PE provided by maternal characteristics and medical history alone. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - L Guerra
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - M Pellegrino
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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O'Gorman N, Nicolaides KH, Poon LCY. The use of ultrasound and other markers for early detection of preeclampsia. WOMEN'S HEALTH (LONDON, ENGLAND) 2016; 12:199-207. [PMID: 26900911 PMCID: PMC5375054 DOI: 10.2217/whe.15.95] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/25/2015] [Indexed: 12/13/2022]
Abstract
Preeclampsia (PE) is a multisystem disorder of pregnancy classically characterized with the onset of hypertension after 20 weeks gestation in the presence of proteinuria. PE typically affects 2-8% of pregnancies and is a leading cause of maternal and perinatal morbidity and mortality. This article reviews the most effective biomarkers used in first trimester screening for PE. It explores their use both in isolation and as part of an algorithm to yield the best detection rates. Screening by a combination of maternal risk factors, uterine artery Doppler, mean arterial pressure, maternal serum PAPP-A and PlGF can identify about 75% of cases of preterm PE for a false-positive rate of 10%. By identifying these patients at high risk for PE, appropriately tailored antenatal surveillance can be instigated and prophylactic pharmacological interventions can be prescribed to improve placentation and ultimately, the outcome for both the mother and fetus.
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Affiliation(s)
- Neil O'Gorman
- Harris Birthright Research Centre of Fetal Medicine, King's College Hospital, London, UK
| | - Kypros H Nicolaides
- Harris Birthright Research Centre of Fetal Medicine, King's College Hospital, London, UK
| | - Liona CY Poon
- Harris Birthright Research Centre of Fetal Medicine, King's College Hospital, London, UK
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O’Gorman N, Wright D, Syngelaki A, Akolekar R, Wright A, Poon LC, Nicolaides KH. Competing risks model in screening for preeclampsia by maternal factors and biomarkers at 11-13 weeks gestation. Am J Obstet Gynecol 2016; 214:103.e1-103.e12. [PMID: 26297382 DOI: 10.1016/j.ajog.2015.08.034] [Citation(s) in RCA: 307] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 08/06/2015] [Accepted: 08/12/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Preeclampsia affects approximately 3% of all pregnancies and is a major cause of maternal and perinatal morbidity and death. In the last decade, extensive research has been devoted to early screening for preeclampsia with the aim of reducing the prevalence of the disease through pharmacologic intervention in the high-risk group starting from the first trimester of pregnancy. OBJECTIVE The purpose of this study was to develop a model for preeclampsia based on maternal demographic characteristics and medical history (maternal factors) and biomarkers. STUDY DESIGN The data for this study were derived from prospective screening for adverse obstetric outcomes in women who attended for their routine first hospital visit at 11-13 weeks gestation in 2 maternity hospitals in England. We screened 35,948 singleton pregnancies that included 1058 pregnancies (2.9%) that experienced preeclampsia. Bayes theorem was used to combine the a priori risk from maternal factors with various combinations of uterine artery pulsatility index, mean arterial pressure, serum pregnancy-associated plasma protein-A, and placental growth factor multiple of the median values. Five-fold cross validation was used to assess the performance of screening for preeclampsia that delivered at <37 weeks gestation (preterm-preeclampsia) and ≥37 weeks gestation (term-preeclampsia) by models that combined maternal factors with individual biomarkers and their combination with screening by maternal factors alone. RESULTS In pregnancies that experienced preeclampsia, the values of uterine artery pulsatility index and mean arterial pressure were increased, and the values of serum pregnancy-associated plasma protein-A and placental growth factor were decreased. For all biomarkers, the deviation from normal was greater for early than late preeclampsia; therefore, the performance of screening was related inversely to the gestational age at which delivery became necessary for maternal and/or fetal indications. Combined screening by maternal factors, uterine artery pulsatility index, mean arterial pressure, and placental growth factor predicted 75% (95% confidence interval, 70-80%) of preterm-preeclampsia and 47% (95% confidence interval, 44-51%) of term-preeclampsia, at a false-positive rate of 10%; inclusion of pregnancy-associated plasma protein-A did not improve the performance of screening. Such detection rates are superior to the respective values of 49% (95% confidence interval, 43-55%) and 38% (34-41%) that were achieved by screening with maternal factors alone. CONCLUSION Combination of maternal factors and biomarkers provides effective first-trimester screening for preterm-preeclampsia.
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Lesmes C, Gallo DM, Gonzalez R, Poon LC, Nicolaides KH. Prediction of small-for-gestational-age neonates: screening by maternal serum biochemical markers at 19-24 weeks. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:341-349. [PMID: 25969963 DOI: 10.1002/uog.14899] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/05/2015] [Accepted: 05/07/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To investigate the value of maternal serum concentrations of placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG) and α-fetoprotein (AFP) at 19-24 weeks' gestation, in combination with maternal factors and fetal biometry, in the prediction of delivery of small-for-gestational-age (SGA) neonates, in the absence of pre-eclampsia (PE) and examine the potential value of such assessment in deciding whether the third-trimester scan should be performed at 32 and/or 36 weeks' gestation. METHODS This was a screening study in 9715 singleton pregnancies, including 481 (5.0%) that delivered SGA neonates with birth weight < 5(th) percentile (SGA < 5(th) ), in the absence of PE. Multivariable logistic regression analysis was used to determine if screening by a combination of maternal factors, Z-scores of fetal head circumference, abdominal circumference and femur length, and log10 multiples of the median (MoM) values of PlGF, sFlt-1, PAPP-A, free β-hCG or AFP had a significant contribution to the prediction of SGA neonates. A model was developed in selecting the gestational age for third-trimester assessment, at 32 and/or 36 weeks, based on the results of screening at 19-24 weeks. RESULTS Compared to the normal group, the mean log10 MoM value of PlGF was lower, AFP was higher and sFlt-1, PAPP-A and free β-hCG were not significantly different in the SGA < 5(th) group that delivered < 37 weeks. The detection rate (DR) of combined screening by maternal factors, fetal biometry and serum PlGF and AFP at 19-24 weeks was 100%, 76% and 38% for SGA < 5(th) delivering < 32, 32-36 and ≥ 37 weeks' gestation, respectively, at a false-positive rate (FPR) of 10%. In a hypothetical model, it was estimated that, if the desired objective of prenatal screening is to predict about 80% of the cases of SGA < 5(th) , it would be necessary to select 11% of the population at the 19-24-week assessment to be reassessed at 32 weeks and 46% to be reassessed at 36 weeks; 54% would not require a third-trimester scan. CONCLUSION Prenatal prediction of a high proportion of SGA neonates necessitates the undertaking of screening in the third trimester of pregnancy, in addition to assessment in the second trimester, and the timing of such screening, at 32 and/or 36 weeks, should be contingent on the results of the assessment at 19-24 weeks.
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Affiliation(s)
- C Lesmes
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - D M Gallo
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - R Gonzalez
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - L C Poon
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Bakalis S, Gallo DM, Mendez O, Poon LC, Nicolaides KH. Prediction of small-for-gestational-age neonates: screening by maternal biochemical markers at 30-34 weeks. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:208-215. [PMID: 25826797 DOI: 10.1002/uog.14861] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/25/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To investigate the potential value of serum placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG) and α-fetoprotein (AFP) at 30-34 weeks' gestation in the prediction of delivery of small-for-gestational-age (SGA) neonates, in the absence of pre-eclampsia (PE). METHODS This was a screening study in singleton pregnancies at 30-34 weeks' gestation, including 490 that delivered SGA neonates and 9360 cases that were unaffected by SGA, PE or gestational hypertension (normal outcome). Multivariable logistic regression analysis was used to determine if screening by serum PlGF, sFlt-1, PAPP-A, free β-hCG and AFP, individually or in combination, improved the prediction of SGA neonates provided by screening with maternal characteristics and medical history (maternal factors), and estimated fetal weight (EFW) from fetal head circumference, abdominal circumference and femur length. RESULTS Compared to the normal group, the mean log10 multiples of the median (MoM) values of PlGF and AFP were significantly lower and the mean log10 MoM values of sFlt-1 and free β-hCG were significantly higher in the SGA group with a birth weight < 5(th) percentile (SGA < 5(th)) delivering < 5 weeks following assessment. The best model for prediction of SGA was provided by a combination of maternal factors, EFW and serum PlGF. Such combined screening, predicted, at a 10% false-positive rate, 85%, 93% and 92% of SGA neonates delivering < 5 weeks following assessment with birth weight < 10(th), < 5(th) and < 3(rd) percentiles, respectively; the respective detection rates of combined screening for SGA neonates delivering ≥ 5 weeks following assessment were 57%, 64% and 71%. CONCLUSION Combined screening by maternal factors, EFW and serum PlGF at 30-34 weeks' gestation can identify a high proportion of pregnancies that subsequently deliver SGA neonates.
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Affiliation(s)
- S Bakalis
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - D M Gallo
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - O Mendez
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - L C Poon
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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