Implementation of First-Trimester Screening and Prevention of Preeclampsia: A Stepped Wedge Cluster-Randomized Trial in Asia

Effect of aspirin on biomarker profile in women at high risk for preeclampsia

BACKGROUND

There is limited evidence in the literature regarding the temporal changes of preeclampsia-related biomarkers during pregnancy in high-risk women who develop preeclampsia despite the administration of aspirin prophylaxis.

OBJECTIVE

This study aimed to compare the temporal changes in mean arterial pressure, uterine artery pulsatility index, placental growth factor, and soluble fms-like tyrosine kinase-1 across gestation in women identified as having high risk for preterm preeclampsia receiving aspirin prophylaxis and low-risk women without aspirin treatment.

STUDY DESIGN

This was a prospective longitudinal nested case-control study of 2007 women with singleton pregnancies who participated in the first-trimester screen-and-prevent program for preeclampsia at the Prince of Wales Hospital, Hong Kong Special Administrative Region, China, between January 2020 and May 2023. The risk of developing preterm preeclampsia was determined using the Fetal Medicine Foundation triple test (maternal factors, mean arterial pressure, uterine artery pulsatility index, and placental growth factor). High-risk women (adjusted risk ≥1:100) were administered a daily dose of aspirin at either 100 or 160 mg according to maternal weight, starting before 16 weeks until 36 weeks or until delivery or the onset of preeclampsia before 36 weeks. Low-risk women were matched according to maternal age, weight, and the date of the scan. The participants were followed up at 12 to 15+6, 20 to 24+6, and 30 to 37+6 weeks to measure mean arterial pressure, uterine artery pulsatility index, placental growth factor, and soluble fms-like tyrosine kinase-1 at each visit. The level of biomarker was expressed as multiple of the median. Log10 transformation was applied to fit the data to a Gaussian distribution before statistical analysis. A linear mixed-effects analysis was performed to compare the longitudinal changes of these biomarkers across gestation between the study groups.

RESULTS

Our study involved 403 low-risk women without preeclampsia, 1471 high-risk women without preeclampsia, and 133 high-risk women who developed preeclampsia. The low-risk group had significantly lower estimated marginal mean log10 mean arterial pressure multiple of the median, log10 uterine artery pulsatility index multiple of the median, and log10 soluble fms-like tyrosine kinase-1 multiple of the median, and higher estimated marginal mean log10 placental growth factor multiple of the median across gestation compared with the high-risk groups (P<.001). Among high-risk women, those who developed preeclampsia exhibited a significantly higher estimated marginal mean log10 mean arterial pressure multiple of the median (0.06378 vs 0.02985; P<.001), log10 uterine artery pulsatility index multiple of the median (0.08651 vs 0.02226; P<.001), and log10 soluble fms-like tyrosine kinase-1 multiple of the median (0.13204 vs 0.01234; P<.001), and lower estimated marginal mean log10 placental growth factor multiple of the median (-0.33504 vs -0.16388; P<.001) across gestation compared with those without preeclampsia. In the individual gestational time point analysis, compared with high-risk women without preeclampsia, those who developed preeclampsia exhibited higher log10 mean arterial pressure multiple of the median in all 3 trimesters, higher log10 uterine artery pulsatility index multiple of the median and lower log10 placental growth factor multiple of the median in the second and third trimesters, and higher log10 soluble fms-like tyrosine kinase-1 multiple of the median in the third trimester.

CONCLUSION

This study demonstrated that high-risk women who developed preeclampsia consistently exhibited high mean arterial pressure levels from the first trimester that remained unchanged during pregnancy, high uterine artery pulsatility index levels and low placental growth factor levels starting from the second trimester, and high soluble fms-like tyrosine kinase-1 levels in the third trimester compared with those who did not develop preeclampsia despite the administration of low-dose aspirin. These findings underscore the role of these biomarkers in further risk stratification for the development of preeclampsia among high-risk women following aspirin administration.

Development and validation of a preeclampsia prediction model for the first and second trimester pregnancy based on medical history

OBJECTIVE

The study aimed to identify the risk factors of preeclampsia (PE) and establish a novel prediction model.

STUDY DESIGN

A retrospective, single-center analysis was conducted using clinical data from 5099 pregnant women who gave birth at Peking University People's Hospital between June 2015 and December 2020 who had placental growth factor (PIGF) levels records at 13-20 + 6 gestation weeks. The participants were randomly divided into a training set (70%, n = 3569) and a validation set (30%, n = 1030), between which the consistency was checked, and the analysis was performed according to whether PE occurred during pregnancy. Factors with univariate logistic analysis outcome of p < 0.2 were incorporated into the multivariate logistic regression analysis model, then variable selection by stepwise regression with AIC as the criterion was executed to finally identify the variables used for modeling. The model's discriminative ability was assessed using the receiver operating characteristic (ROC) curve, and its calibration was evaluated through calibration curves and Hosmer-Lemesow test. In addition, decision curve analysis (DCA) was used for clinical net benefit appraisal.

RESULTS

Logistic regression analysis identified nine risk factors for PE, including: maternal age (OR = 1.072, 95%CI = 1.025-1.120), parity(OR = 0.718,95%CI = 0.470-1.060), pre-pregnancy BMI (OR = 2.842,95%CI = 1.957-4.106), family hypertension history (OR = 3.604,95%CI = 2.433-5.264), pregestational diabetes mellitus(PGDM) (OR = 8.399, 95%CI = 4.138-15.883), pregnancy complicating nephropathy (OR = 7.931, 95% CI = 2.584-20.258),pregnancy complicating immune system disorders (OR = 3.134, 95% CI = 1.624-5.525), mean arterial pressure(MAP) at 11-13 + 6 gestational weeks (OR = 1.098, 95% CI = 1.078-1.119) and PIGF (OR = 0.647, 95% CI = 0.448-0.927) at 13-20 + 6 gestational weeks (P < 0.05). The restricted spline regression analysis (RCS) analysis results showed that PIGF and the risk of PE presented an approximately "L-shaped" relationship, with the risk of PE rising sharply with the decrease of PIGF when PIGF < 90 pg/ml, and little change with the increase of PIGF when PIGF > 90 pg/ml. A risk prediction model for PE during the first and second trimester was constructed based on the above selected 11 factors. The area under the ROC curve (AUC) for the model was 0.781(95%CI = 0.709-0.853), and the sensitivity and specificity at the optimal cut-off value (threshold probability) were 0.571 and 0.879 respectively. Chi-square of 9.616 and P value of 0.293 from Hosmer-Lemeshow test indicated that the model was well calibrated. Finally, the model showed good clinical net benefits in the threshold range of 0.03-0.3.

CONCLUSION

The incidence of PE was associated with maternal age, pre-pregnancy weight and BMI, family hypertension history, PGDM, pregnancy complicating nephropathy, gestational complicating immune system disorders, blood pressure (systolic, diastolic, mean arterial pressure) at 11-13 + 6 gestational weeks, and PIGF at 13-20 + 6 gestational weeks. When PIGF < 90 pg/ml at 13-20 + 6 gestational week, the risk of PE increased significantly with the reduction of PIGF. The nomogram based on the above results was simpler and more practical in clinical application for PE predicting during the first and second trimester, and may provide an important reference for doctors and patients.

Comparison of first trimester preeclampsia combined screening performances with various approaches in the Indonesian population

INTRODUCTION

This study aimed to compare Fetal Medicine Foundation (FMF), Indonesian Maternal and Children Health Handbook (MCH-HB), and Indonesian Prenatal Institute (IPI) models for predicting PE.

MATERIALS/SUBJECTS AND METHODS

Maternal risk factors, biophysical, and biochemical markers were recorded from women screened for PE at 11-14 gestational weeks. The receiving operator curve (ROC) analysis was used to compare the detection rate (DR) among prediction models.

RESULTS

For all PE at a 10% false-positive rate (FPR), FMF had a DR 62.9%; MCH-HB had a DR 50.0%; IPI had a DR 66.9%. For early-onset PE, at 10% FPR FMF had a DR 80.3%; MCH-HB had a DR 71.4%; IPI had a DR 81.5%. For preterm PE at 10% FPR, FMF had a DR 70.2%; MCH-HB had a DR 38.5%; IPI had a DR 66.9%.

DISCUSSION

IPI algorithm is comparable to FMF and outperforms MCH-HB algorithm for all, early-onset, and preterm PE screening.

Impact of Aspirin on Timing of Birth in Pregnancies With Clinical Manifestations of Placental Dysfunction: Evidence From a Multicentre Randomised Clinical Trial

OBJECTIVE

To examine whether aspirin delays gestational age at delivery (GAD) in pregnancies with placental dysfunction (PD) phenotypes (preeclampsia [PE], small-for-gestational-age [SGA], placental abruption and/or stillbirth).

DESIGN

A secondary analysis of a multicentre stepped-wedge cluster randomised trial.

SETTING

18 maternity/diagnostic units in Asia.

POPULATION

Singleton pregnancies examined at 11-13+6 weeks.

METHODS

A model in which the effect of aspirin is to delay the GAD in pregnancies with PD was developed.

MAIN OUTCOME MEASURES

GAD in pregnancies with PD.

RESULTS

Aspirin administration was associated with a significant reduction in PD < 32 weeks (adjusted relative risk 0.543, 95% CI: 0.330-0.864), with a trend for an increase of PD ≥ 32 weeks (test for trend, p-value = 0.0018). Similar findings were observed individually for PE, SGA and/or placental abruption. At 24 weeks, the aspirin-induced prolongation of pregnancies with PD was 2.85 weeks (95% CI: 0.44-5.40), and this effect was decreased by -0.19 weeks (95% CI: -0.33 to -0.05) for each week of gestation; therefore, at 28 and 32 weeks' gestation, the aspirin-induced prolongation was 2.09 and 1.33 weeks, respectively.

CONCLUSIONS

In this secondary analysis of a cluster randomised trial, women at high risk of PE who are destined to develop a clinical spectrum of PD may benefit from longer pregnancy duration through aspirin administration in early pregnancy. Aspirin may delay the GAD due to PD, particularly benefiting those deliveries that would occur at earlier gestations without aspirin administration.

Hypertension in Pregnancy and Postpartum: Current Standards and Opportunities to Improve Care

Hypertension in pregnancy contributes substantially to maternal morbidity and mortality, persistent hypertension, and rehospitalization. Hypertensive disorders of pregnancy are also associated with a heightened risk of cardiovascular disease, and timely recognition and modification of associated risk factors is crucial in optimizing long-term maternal health. During pregnancy, there are expected physiologic alterations in blood pressure (BP); however, pathophysiologic alterations may also occur, leading to preeclampsia and gestational hypertension. The diagnosis and effective management of hypertension during pregnancy is essential to mitigate maternal risks, such as acute kidney injury, stroke, and heart failure, while balancing potential fetal risks, such as growth restriction and preterm birth due to altered uteroplacental perfusion. In the postpartum period, innovative and multidisciplinary care solutions that include postpartum maternal health clinics can help optimize short- and long-term care through enhanced BP management, screening of cardiovascular risk factors, and discussion of lifestyle modifications for cardiovascular disease prevention. As an adjunct to or distinct from postpartum clinics, home BP monitoring programs have been shown to improve BP ascertainment across diverse populations and to lower BP in the months after delivery. Because of concerns about pregnant patients being a vulnerable population for research, there is little evidence from trials examining the diagnosis and treatment of hypertension in pregnant and postpartum individuals. As a result, national and international guidelines differ in their recommendations, and more studies are needed to bolster future guidelines and establish best practices to achieve optimal cardiovascular health during and after pregnancy. Future research should focus on refining treatment thresholds and optimal BP range peripartum and postpartum and evaluating interventions to improve postpartum and long-term maternal cardiovascular outcomes that would advance evidence-based care and improve outcomes worldwide for people with hypertensive disorders of pregnancy.

Antioxidant Properties of Albumin and Diseases Related to Obstetrics and Gynecology

Albumin, the most abundant protein, contributes significantly to various physiological processes, indicating its multifunctional properties. It has drawn the attention of scientists and physicians because of its primary role in maintaining osmotic pressure and involvement in transporting numerous small molecules, including hormones, fatty acids, and drugs. A growing body of evidence has recently illustrated an additional aspect of albumin's antioxidant properties. Therefore, based on recent research findings, this review article delves into the molecular and biochemical aspects of albumin's antioxidative capabilities. We highlight the multifaceted significance of proteins in oxidative stress and their relation to pathologies in obstetrics and gynecology. In particular, we focused on preeclampsia, in which oxidative stress is closely involved in the pathogenesis, and renal dysfunction leads to increased albumin excretion into the urine, resulting in hypoalbuminemia. In addition, we discussed the role of albumin in preeclampsia pathogenesis, diagnosis, and patient prognosis. Understanding the antioxidant properties of albumin opens new avenues for therapeutic intervention and sheds light on novel strategies for combating preeclampsia associated with oxidative damage. In this study, we employed the PubMed database to search for articles that assessed the antioxidant properties of albumin, with a specific focus on obstetric diseases, particularly preeclampsia. The last update of the search was conducted in November 2024.

Prevention of Pregnancy Complications Using a Multimodal Lifestyle, Screening, and Medical Model

Prevention of pregnancy complications related to the "great obstetrical syndromes" (preeclampsia, fetal growth restriction, spontaneous preterm labor, and stillbirth) is a global research and clinical management priority. These syndromes share many common pathophysiological mechanisms that may contribute to altered placental development and function. The resulting adverse pregnancy outcomes are associated with increased maternal and perinatal morbidity and mortality and increased post-partum risk of cardiometabolic disease. Maternal nutritional and environmental factors are known to play a significant role in altering bidirectional communication between fetal-derived trophoblast cells and maternal decidual cells and contribute to abnormal placentation. As a result, lifestyle-based interventions have increasingly been recommended before, during, and after pregnancy, in order to reduce maternal and perinatal morbidity and mortality and decrease long-term risk. Antenatal screening strategies have been developed following extensive studies in diverse populations. Multivariate preeclampsia screening using a combination of maternal, biophysical, and serum biochemical markers is recommended at 11-14 weeks' gestation and can be performed at the same time as the first-trimester ultrasound and blood tests. Women identified as high-risk can be offered prophylactic low dose aspirin and monitored with angiogenic factor assessment from 22 weeks' gestation, in combination with clinical assessment, serum biochemistry, and ultrasound. Lifestyle factors can be reassessed during counseling related to antenatal screening interventions. The integration of lifestyle interventions, pregnancy screening, and medical management represents a conceptual advance in pregnancy care that has the potential to significantly reduce pregnancy complications and associated later life cardiometabolic adverse outcomes.