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Al Ghadban Y, Du Y, Charnock-Jones DS, Garmire LX, Smith GCS, Sovio U. Prediction of spontaneous preterm birth using supervised machine learning on metabolomic data: A case-cohort study. BJOG 2024; 131:908-916. [PMID: 37984426 DOI: 10.1111/1471-0528.17723] [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: 03/20/2023] [Revised: 09/11/2023] [Accepted: 11/02/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVES To identify and internally validate metabolites predictive of spontaneous preterm birth (sPTB) using multiple machine learning methods and sequential maternal serum samples, and to predict spontaneous early term birth (sETB) using these metabolites. DESIGN Case-cohort design within a prospective cohort study. SETTING Cambridge, UK. POPULATION OR SAMPLE A total of 399 Pregnancy Outcome Prediction study participants, including 98 cases of sPTB. METHODS An untargeted metabolomic analysis of maternal serum samples at 12, 20, 28 and 36 weeks of gestation was performed. We applied six supervised machine learning methods and a weighted Cox model to measurements at 28 weeks of gestation and sPTB, followed by feature selection. We used logistic regression with elastic net penalty, followed by best subset selection, to reduce the number of predictive metabolites further. We applied coefficients from the chosen models to measurements from different gestational ages to predict sPTB and sETB. MAIN OUTCOME MEASURES sPTB and sETB. RESULTS We identified 47 metabolites, mostly lipids, as important predictors of sPTB by two or more methods and 22 were identified by three or more methods. The best 4-predictor model had an optimism-corrected area under the receiver operating characteristics curve (AUC) of 0.703 at 28 weeks of gestation. The model also predicted sPTB in 12-week samples (0.606, 95% CI 0.544-0.667) and 20-week samples (0.657, 95% CI 0.597-0.717) and it predicted sETB in 36-week samples (0.727, 95% CI 0.606-0.849). A lysolipid, 1-palmitoleoyl-GPE (16:1)*, was the strongest predictor of sPTB at 12 weeks of gestation (0.609, 95% CI 0.548-0.670), 20 weeks (0.630, 95% CI 0.569-0.690) and 28 weeks (0.660, 95% CI 0.599-0.722), and of sETB at 36 weeks (0.739, 95% CI 0.618-0.860). CONCLUSIONS We identified and internally validated maternal serum metabolites predictive of sPTB. A lysolipid, 1-palmitoleoyl-GPE (16:1)*, is a novel predictor of sPTB and sETB. Further validation in external populations is required.
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Affiliation(s)
- Yasmina Al Ghadban
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Yuheng Du
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - D Stephen Charnock-Jones
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Lana X Garmire
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Centre for Trophoblast Research (CTR), Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
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Sovio U, Gaccioli F, Cook E, Charnock-Jones DS, Smith GCS. Association between adverse pregnancy outcome and placental biomarkers in the first trimester: A prospective cohort study. BJOG 2024; 131:823-831. [PMID: 37822261 DOI: 10.1111/1471-0528.17691] [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: 07/06/2023] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE To determine the inter-relationships between five first-trimester biomarkers (pregnancy associated plasma protein A [PAPP-A], alpha-fetoprotein [AFP], beta human chorionic gonadotrophin [beta-hCG], placenta growth factor [PlGF] and soluble fms-like tyrosine kinase receptor-1 [sFlt-1]) and a range of adverse pregnancy outcomes (APOs). DESIGN Prospective cohort study of nulliparous singleton pregnancy. SETTING Cambridge, UK. POPULATION OR SAMPLE 4056 pregnancy outcome prediction study participants. METHODS The biomarker concentrations were measured in maternal serum at ~12 weeks of gestation. Univariable analysis of APOs was performed using logistic regression. Multivariable analysis used best subsets logistic regression with cross-validation. MAIN OUTCOME MEASURES Pre-eclampsia (PE), small for gestational age (SGA), including severe SGA (birthweight <3rd), fetal growth restriction (FGR), preterm birth (PTB, both induced and spontaneous [iPTB and sPTB, respectively]), pre-viable loss and stillbirth, plus combinations of outcomes. RESULTS Lower values of PAPP-A, PlGF and sFlt-1 and higher values of AFP were associated with FGR (OR for 1 SD higher value 0.59 [95% CI 0.48-0.74], OR 0.56 [95% CI 0.44-0.70], OR 0.68 [95% CI 0.54-0.87] and OR 1.53 [95% CI 1.25-1.88]), severe SGA (OR 0.59 [95% CI 0.49-0.72], OR 0.71 [95% CI 0.57-0.87], OR 0.74 [95% CI 0.60-0.91] and OR 1.41 [95% CI 1.17-1.71]), sPTB (OR 0.61 [95% CI 0.50-0.73], OR 0.79 [95% CI 0.66-0.96], OR 0.57 [95% CI 0.47-0.70] and OR 1.41 [95% CI 1.18-1.67]) and iPTB (OR 0.72 [95% CI 0.57-0.91], OR 0.62 [95% CI 0.49-0.78], OR 0.71 [95% CI 0.56-0.90] and OR 1.44 [95% CI 1.16-1.78]), respectively. When combinations of biomarkers were assessed, PAPP-A and AFP were independently associated with severe SGA; PAPP-A alone with PE + PTB; PlGF alone with severe PE; PlGF, beta-hCG, AFP and PAPP-A with the combination of PE and SGA; AFP and sFlt-1 with sPTB; and AFP and PlGF with iPTB. CONCLUSIONS Combinations of first-trimester placental biomarkers are associated with APOs. However, the patterns vary for different types of APO, indicating heterogeneity in the underlying pathophysiological pathways.
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Affiliation(s)
- Ulla Sovio
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
- Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research (CTR), University of Cambridge, Cambridge, UK
| | - Francesca Gaccioli
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
- Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research (CTR), University of Cambridge, Cambridge, UK
| | - Emma Cook
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - D Stephen Charnock-Jones
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
- Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research (CTR), University of Cambridge, Cambridge, UK
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
- Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research (CTR), University of Cambridge, Cambridge, UK
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Cagan M, Okuducu U, Donmez HG, Beksac MS. Singleton pregnancy losses before gestational week 22 among patients with autoimmune disorders and Methylenetetrahydrofolate reductase polymorphisms. Hum Antibodies 2022; 30:59-65. [PMID: 35001885 DOI: 10.3233/hab-211517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The rates of pregnancy losses (PLs) are increased by maternal risk factors such as autoimmune disorders (AD) and methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms. OBJECTIVE To evaluate singleton PLs before gestational week (gw) 22 among patients with AD and MTHFR polymorphisms. METHODS Totally, 1108 singleton pregnancies in 243 women were categorized as: 1) 148 pregnancies in 33 patients with AD, 2) 316 pregnancies in 66 patients with MTHFR polymorphisms, 3) 644 pregnancies in 144 patients with AD +MTHFR polymorphisms. PLs were classified into subgroups: a) Chemical Pregnancy(CP), b) Blighted Ovum(BO), c) gw ⩽ 10, d) gw11-14 e) gw15-22, f) Ectopic Pregnancy(EP), g) Trophoblastic Disease(TD). Obstetric histories were compared using Beksac Obstetrics Index (BOI): [number of living child + (π/10)]/gravida. RESULTS PL rates before gw22 were 39.2% (58/148), 33.2% (105/316), and 36.3% (234/644) in AD, MTHFR, and AD +MTHFR groups, respectively (p= 0.421). The rate of Pre-Prenatal Screening Period fetal losses (CP + BO + gw ⩽ 10 fetal losses + EP + TD) were 84.8%, 75.9%, and 77.8% in AD, MTHFR, and AD +MTHFR, respectively (p= 0.264). Gravidity ⩽ 4 versus those with gravidity ⩾ 5 had statistically significant differences in BOI (p< 0.001). CONCLUSIONS PL rate before gw22 among singleton pregnancies with AD and/or MTHFR polymorphisms was 35.8%. The clinical findings seem to be more complicated in patients with gravidity ⩾ 5.
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Affiliation(s)
- Murat Cagan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ummuhan Okuducu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Hanife Guler Donmez
- Department of Biology, Faculty of Science, Hacettepe University, Ankara, Turkey
| | - Mehmet Sinan Beksac
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Sherrell HC, Dunn LTB, Horey D, Flenady V, Kumar S. Women's and clinician's acceptability of participation in a hypothetical obstetric randomized controlled trial: a qualitative survey. J Matern Fetal Neonatal Med 2021; 35:9163-9169. [PMID: 34965816 DOI: 10.1080/14767058.2021.2020236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Involving patients and consumers in research design helps ensure relevance for those affected by the problem being investigated and can optimize recruitment to clinical trials. This is particularly important when conducting research involving pregnant women. AIMS We investigated women's motivations to participate in a hypothetical randomized control trial (RCT) of a third-trimester screening test for intrapartum fetal compromise (IFC) and adverse perinatal outcomes. MATERIALS AND METHODS Women attending for routine antenatal care at a tertiary center were invited to complete a short, anonymized patient acceptability survey. The survey was developed with the assistance of the Perinatal Society of Australia and New Zealand's Consumer Advisory Panel and consisted of Likert scales and open-ended questions. It was designed to ascertain women's responses to research issues, particularly the acceptability of being randomized to a non-revealed arm of a screening test RCT. RESULTS 100 pregnant women took part; 40% indicated that they would agree/strongly agree to participate in a hypothetical RCT regardless of whether they were given the result of a screening test and 31% were unsure. Randomization to either an intervention or control group was acceptable to 47%, 30% were unsure and 23% were not willing to be randomized. Reasons to participate included the desire to contribute to research and to improve pregnancy care. CONCLUSIONS Participation in an RCT of a screening test for IFC involving non-disclosure of the test result was acceptable to a large minority of pregnant women. This finding supports the feasibility of conducting a large-scale study of this design.
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Affiliation(s)
- Helen C Sherrell
- Mater Research Institute - University of Queensland, Brisbane, Australia
| | - Liam T B Dunn
- Mater Research Institute - University of Queensland, Brisbane, Australia
| | - Dell Horey
- NHMRC Stillbirth Centre for Research Excellence, Mater Research Institute - University of Queensland, Brisbane, Australia.,School of Psychology & Public Health, La Trobe University, Melbourne, Australia
| | - Vicki Flenady
- Mater Research Institute - University of Queensland, Brisbane, Australia.,Mater Mothers' Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,NHMRC Stillbirth Centre for Research Excellence, Mater Research Institute - University of Queensland, Brisbane, Australia
| | - Sailesh Kumar
- Mater Research Institute - University of Queensland, Brisbane, Australia.,Mater Mothers' Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,NHMRC Stillbirth Centre for Research Excellence, Mater Research Institute - University of Queensland, Brisbane, Australia
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Sovio U, Gaccioli F, Cook E, Charnock-Jones DS, Smith GCS. Slowing of fetal growth and elevated maternal serum sFLT1:PlGF are associated with early term spontaneous labor. Am J Obstet Gynecol 2021; 225:520.e1-520.e10. [PMID: 33901486 PMCID: PMC8568041 DOI: 10.1016/j.ajog.2021.04.232] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 12/17/2022]
Abstract
Background The physiological control of human parturition at term is unknown. Objective This study aimed to test the hypothesis that slowing of fetal growth or elevated maternal serum levels of markers of placental hypoxia in late gestation will be associated with earlier term labor. Study Design We observed 2208 women having first births and performed serial blinded ultrasonography and immunoassay of soluble fms-like tyrosine kinase-1 and placenta growth factor. We estimated the probability of spontaneous delivery from 37 weeks of gestational age concerning (1) fetal growth between 20 and 36 weeks of gestational age and (2) the maternal serum soluble fms-like tyrosine kinase-1–to–placenta growth factor ratio measured at approximately 36 weeks of gestational age. Data were analyzed using logistic regression and Cox regression. Results Fetal size at 36 weeks of gestational age was not independently associated with the timing of delivery at term. However, there was an inverse relationship between fetal growth between 20 weeks of gestational age and 36 weeks of gestational age and the probability of spontaneous labor at 37 to 38 weeks’ gestation (hazard ratio [95% confidence interval] for a 50 percentile increase in abdominal circumference growth velocity, 0.60 [0.47–0.78]; P=.0001). This association was weaker at 39 to 40 weeks’ gestation (0.83 [0.74–0.93]; P=.0013), and there was no association at ≥41 weeks’ gestation. Very similar associations were observed for estimated fetal weight growth velocity. There was a positive relationship between soluble fms-like tyrosine kinase-1–to–placenta growth factor ratio and the probability of spontaneous labor at 37 to 38 weeks’ gestation (hazard ratio [95% confidence interval] for a 50 percentile increase in soluble fms-like tyrosine kinase-1–to–placenta growth factor ratio, 3.05 [2.32–4.02]; P<.0001). This association was weaker at 39 to 40 weeks’ gestation (1.46 [1.30–1.63]; P<.0001), and there was no association at ≥41 weeks’ gestation. Adjustment for maternal characteristics was without material effect on any of these associations. Conclusion Slowing of fetal growth and biomarkers of placental insufficiency were associated with an increased probability of early onset of spontaneous term labor. We speculated that progressive placental insufficiency may be a physiological phenomenon that occurs with advancing gestational age near and at term and promotes the initiation of labor.
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Affiliation(s)
- Ulla Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom; NIHR Cambridge Biomedical Research Centre, Cambridge, United Kingdom; Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom.
| | - Francesca Gaccioli
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom; NIHR Cambridge Biomedical Research Centre, Cambridge, United Kingdom; Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Emma Cook
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom; NIHR Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - D Stephen Charnock-Jones
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom; NIHR Cambridge Biomedical Research Centre, Cambridge, United Kingdom; Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom; NIHR Cambridge Biomedical Research Centre, Cambridge, United Kingdom; Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom.
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McBride N, Yousefi P, Sovio U, Taylor K, Vafai Y, Yang T, Hou B, Suderman M, Relton C, Smith GCS, Lawlor DA. Do Mass Spectrometry-Derived Metabolomics Improve the Prediction of Pregnancy-Related Disorders? Findings from a UK Birth Cohort with Independent Validation. Metabolites 2021; 11:530. [PMID: 34436471 PMCID: PMC8399752 DOI: 10.3390/metabo11080530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/23/2021] [Accepted: 07/30/2021] [Indexed: 12/01/2022] Open
Abstract
Many women who experience gestational diabetes (GDM), gestational hypertension (GHT), pre-eclampsia (PE), have a spontaneous preterm birth (sPTB) or have an offspring born small/large for gestational age (SGA/LGA) do not meet the criteria for high-risk pregnancies based upon certain maternal risk factors. Tools that better predict these outcomes are needed to tailor antenatal care to risk. Recent studies have suggested that metabolomics may improve the prediction of these pregnancy-related disorders. These have largely been based on targeted platforms or focused on a single pregnancy outcome. The aim of this study was to assess the predictive ability of an untargeted platform of over 700 metabolites to predict the above pregnancy-related disorders in two cohorts. We used data collected from women in the Born in Bradford study (BiB; two sub-samples, n = 2000 and n = 1000) and the Pregnancy Outcome Prediction study (POPs; n = 827) to train, test and validate prediction models for GDM, PE, GHT, SGA, LGA and sPTB. We compared the predictive performance of three models: (1) risk factors (maternal age, pregnancy smoking, BMI, ethnicity and parity) (2) mass spectrometry (MS)-derived metabolites (n = 718 quantified metabolites, collected at 26-28 weeks' gestation) and (3) combined risk factors and metabolites. We used BiB for the training and testing of the models and POPs for independent validation. In both cohorts, discrimination for GDM, PE, LGA and SGA improved with the addition of metabolites to the risk factor model. The models' area under the curve (AUC) were similar for both cohorts, with good discrimination for GDM (AUC (95% CI) BiB 0.76 (0.71, 0.81) and POPs 0.76 (0.72, 0.81)) and LGA (BiB 0.86 (0.80, 0.91) and POPs 0.76 (0.60, 0.92)). Discrimination was improved for the combined models (compared to the risk factors models) for PE and SGA, with modest discrimination in both studies (PE-BiB 0.68 (0.58, 0.78) and POPs 0.66 (0.60, 0.71); SGA-BiB 0.68 (0.63, 0.74) and POPs 0.64 (0.59, 0.69)). Prediction for sPTB was poor in BiB and POPs for all models. In BiB, calibration for the combined models was good for GDM, LGA and SGA. Retained predictors include 4-hydroxyglutamate for GDM, LGA and PE and glycerol for GDM and PE. MS-derived metabolomics combined with maternal risk factors improves the prediction of GDM, PE, LGA and SGA, with good discrimination for GDM and LGA. Validation across two very different cohorts supports further investigation on whether the metabolites reflect novel causal paths to GDM and LGA.
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Affiliation(s)
- Nancy McBride
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol BS8 2BN, UK; (P.Y.); (K.T.); (M.S.); (C.R.); (D.A.L.)
- NIHR Bristol Biomedical Research Centre, University of Bristol, Bristol BS8 2BN, UK
- Department of Population Health Sciences, University of Bristol, Bristol BS8 2BN, UK
| | - Paul Yousefi
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol BS8 2BN, UK; (P.Y.); (K.T.); (M.S.); (C.R.); (D.A.L.)
- Department of Population Health Sciences, University of Bristol, Bristol BS8 2BN, UK
| | - Ulla Sovio
- NIHR Cambridge Biomedical Research Centre, Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge CB2 0QQ, UK; (U.S.); (G.C.S.S.)
| | - Kurt Taylor
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol BS8 2BN, UK; (P.Y.); (K.T.); (M.S.); (C.R.); (D.A.L.)
| | - Yassaman Vafai
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford BD9 6DA, UK; (Y.V.); (T.Y.); (B.H.)
| | - Tiffany Yang
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford BD9 6DA, UK; (Y.V.); (T.Y.); (B.H.)
| | - Bo Hou
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford BD9 6DA, UK; (Y.V.); (T.Y.); (B.H.)
| | - Matthew Suderman
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol BS8 2BN, UK; (P.Y.); (K.T.); (M.S.); (C.R.); (D.A.L.)
- Department of Population Health Sciences, University of Bristol, Bristol BS8 2BN, UK
| | - Caroline Relton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol BS8 2BN, UK; (P.Y.); (K.T.); (M.S.); (C.R.); (D.A.L.)
- Department of Population Health Sciences, University of Bristol, Bristol BS8 2BN, UK
| | - Gordon C. S. Smith
- NIHR Cambridge Biomedical Research Centre, Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge CB2 0QQ, UK; (U.S.); (G.C.S.S.)
| | - Deborah A. Lawlor
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol BS8 2BN, UK; (P.Y.); (K.T.); (M.S.); (C.R.); (D.A.L.)
- NIHR Bristol Biomedical Research Centre, University of Bristol, Bristol BS8 2BN, UK
- Department of Population Health Sciences, University of Bristol, Bristol BS8 2BN, UK
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Kwon BN, Lee NR, Kim HJ, Kang YD, Kim JS, Park JW, Jin HJ. Folate metabolizing gene polymorphisms and genetic vulnerability to preterm birth in Korean women. Genes Genomics 2021; 43:937-945. [PMID: 34027569 DOI: 10.1007/s13258-021-01082-3] [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: 05/06/2020] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The folate metabolism that converts homocysteine to methionine is closely related to the accumulation of homocysteine. Increased homocysteine levels lead to an impaired antithrombotic function of the vascular endothelium and uterine-placental circulation, resulting in abnormal pregnancy outcomes. Previous studies have reported that gene polymorphisms in folate metabolism are associated with the development of preterm birth (PTB) in various populations. OBJECTIVE we performed a case-control study to evaluate the association between five polymorphisms in folate metabolic genes (MTHFR, MTR, MTRR, TCN2) and PTB. METHODS In this study, a total of 254 subjects were analyzed (111 patients with PTB and 143 women at ≥ 38 weeks of gestation). Genotype and allele frequency differences between patients and control groups and the Hardy-Weinberg equilibrium were assessed using a Chi-square test. For evaluation indicators, odds ratios (ORs) of 95% confidence intervals (CI) were estimated. In addition, we analyzed the combined genotype frequencies of SNPs of folate-metabolizing genes to measure gene-gene interactions for PTB. RESULTS Our results showed that the MTR rs1805087 GG (p = 0.031), and TCN2 rs1801198 CG genotype (OR 0.53, 95% CI 0.288-0.980, p = 0.042) were significantly associated with PTB. The MTHFR rs4846049 AA showed a marginal trend toward significance (OR 0.15, 95% CI 0.018-1.205, p = 0.041). In particular, the combined genotypes, including MTHFR rs1537514 CC-MTRR rs1801394 GG, MTHFR rs1537514 CC-TCN2 rs1801198 CG, and MTR rs1805087 AA-TCN2 rs1801198 CG, have significant interactions with PTB (OR 0.49, 95% CI 0.248-0.992, p < 0.05). CONCLUSION The polymorphisms of folate metabolic genes may have a genetic association with the development of PTB in Korean women. A larger sample set and functional studies are required to further elucidate our findings.
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Affiliation(s)
- Bit Na Kwon
- Department of Biological Sciences, College of Natural Science, Dankook University, Cheonan, Korea
| | - Noo Ri Lee
- Department of Biological Sciences, College of Natural Science, Dankook University, Cheonan, Korea
| | - Hyung Jun Kim
- Department of Biological Sciences, College of Natural Science, Dankook University, Cheonan, Korea
| | - Yun Dan Kang
- Department of Obstetrics and Gynecology, Dankook University Hospital, Cheonan, Korea
| | - Jong Soo Kim
- Department of Obstetrics and Gynecology, Dankook University Hospital, Cheonan, Korea
| | - Jin Wan Park
- Department of Obstetrics and Gynecology, Dankook University Hospital, Cheonan, Korea
| | - Han Jun Jin
- Department of Biological Sciences, College of Natural Science, Dankook University, Cheonan, Korea.
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Moraitis AA, Bainton T, Sovio U, Brocklehurst P, Heazell AE, Thornton JG, Robson SC, Papageorghiou A, Smith GC. Fetal umbilical artery Doppler as a tool for universal third trimester screening: A systematic review and meta-analysis of diagnostic test accuracy. Placenta 2021; 108:47-54. [PMID: 33819861 DOI: 10.1016/j.placenta.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/11/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
The objective of this study was to investigate the accuracy of universal third trimester umbilical artery (UA) Doppler to predict adverse pregnancy outcome at term. We searched Medline, EMBASE, the Cochrane library and ClinicalTrials.gov from inception to October 2020 and we also analyzed previously unpublished data from a prospective cohort study of nulliparous women, the Pregnancy Outcome Prediction (POP) study. We included studies that performed a third-trimester ultrasound scan in unselected, low or mixed risk populations, excluding studies which only included high risk pregnancies. Meta-analysis was performed using the hierarchal summary receiver operating characteristic curve (HSROC) analysis and bivariate logit-normal models. We identified 13 studies (including the POP study) involving 67,764 pregnancies which met our inclusion criteria. The overall quality was variable and only six studies (N = 5777 patients) blinded clinicians to the UA Doppler result. The summary sensitivity and positive likelihood ratio (LR) for small for gestational age (SGA; birthweight <10th centile) were 21.7% (95% CI 13.2-33.6%) and 2.65 (95% CI 1.89-3.72) respectively. The summary positive LR for NICU admission and metabolic acidosis were 1.35 (95% CI 0.93-1.97) and 1.34 (95% CI 0.86-2.08) respectively. The results were similar in the POP study: associations with SGA (positive LR 2.66 [95% CI 2.11-3.36]) and severe SGA (birthweight <3rd centile; positive LR 3.27 [95% CI 2.29-4.68]) but no statistically significant association with neonatal morbidity. We conclude that third trimester UA Doppler has moderate predictive accuracy for small for gestational age but not for indicators of neonatal morbidity in unselected and low risk pregnancies.
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Affiliation(s)
- Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Thomas Bainton
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Alexander Ep Heazell
- Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Biological, Medical and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom; St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Stephen C Robson
- Reproductive and Vascular Biology Group, The Medical School, University of Newcastle, Newcastle, United Kingdom
| | - Aris Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, Oxford, United Kingdom
| | - Gordon Cs Smith
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom.
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10
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Kingdom JC, Smith GCS. Authors' reply re: Next steps to prevent stillbirth associated with growth restriction. BJOG 2021; 128:940-941. [PMID: 33599376 DOI: 10.1111/1471-0528.16641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 11/29/2022]
Affiliation(s)
- John C Kingdom
- Departments of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
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11
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Smith GC, Moraitis AA, Wastlund D, Thornton JG, Papageorghiou A, Sanders J, Heazell AE, Robson SC, Sovio U, Brocklehurst P, Wilson EC. Universal late pregnancy ultrasound screening to predict adverse outcomes in nulliparous women: a systematic review and cost-effectiveness analysis. Health Technol Assess 2021; 25:1-190. [PMID: 33656977 PMCID: PMC7958245 DOI: 10.3310/hta25150] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Currently, pregnant women are screened using ultrasound to perform gestational aging, typically at around 12 weeks' gestation, and around the middle of pregnancy. Ultrasound scans thereafter are performed for clinical indications only. OBJECTIVES We sought to assess the case for offering universal late pregnancy ultrasound to all nulliparous women in the UK. The main questions addressed were the diagnostic effectiveness of universal late pregnancy ultrasound to predict adverse outcomes and the cost-effectiveness of either implementing universal ultrasound or conducting further research in this area. DESIGN We performed diagnostic test accuracy reviews of five ultrasonic measurements in late pregnancy. We conducted cost-effectiveness and value-of-information analyses of screening for fetal presentation, screening for small for gestational age fetuses and screening for large for gestational age fetuses. Finally, we conducted a survey and a focus group to determine the willingness of women to participate in a future randomised controlled trial. DATA SOURCES We searched MEDLINE, EMBASE and the Cochrane Library from inception to June 2019. REVIEW METHODS The protocol for the review was designed a priori and registered. Eligible studies were identified using keywords, with no restrictions for language or location. The risk of bias in studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Health economic modelling employed a decision tree analysed via Monte Carlo simulation. Health outcomes were from the fetal perspective and presented as quality-adjusted life-years. Costs were from the perspective of the public sector, defined as NHS England, and the costs of special educational needs. All costs and quality-adjusted life-years were discounted by 3.5% per annum and the reference case time horizon was 20 years. RESULTS Umbilical artery Doppler flow velocimetry, cerebroplacental ratio, severe oligohydramnios and borderline oligohydramnios were all either non-predictive or weakly predictive of the risk of neonatal morbidity (summary positive likelihood ratios between 1 and 2) and were all weakly predictive of the risk of delivering a small for gestational age infant (summary positive likelihood ratios between 2 and 4). Suspicion of fetal macrosomia is strongly predictive of the risk of delivering a large infant, but it is only weakly, albeit statistically significantly, predictive of the risk of shoulder dystocia. Very few studies blinded the result of the ultrasound scan and most studies were rated as being at a high risk of bias as a result of treatment paradox, ascertainment bias or iatrogenic harm. Health economic analysis indicated that universal ultrasound for fetal presentation only may be both clinically and economically justified on the basis of existing evidence. Universal ultrasound including fetal biometry was of borderline cost-effectiveness and was sensitive to assumptions. Value-of-information analysis indicated that the parameter that had the largest impact on decision uncertainty was the net difference in cost between an induced delivery and expectant management. LIMITATIONS The primary literature on the diagnostic effectiveness of ultrasound in late pregnancy is weak. Value-of-information analysis may have underestimated the uncertainty in the literature as it was focused on the internal validity of parameters, which is quantified, whereas the greatest uncertainty may be in the external validity to the research question, which is unquantified. CONCLUSIONS Universal screening for presentation at term may be justified on the basis of current knowledge. The current literature does not support universal ultrasonic screening for fetal growth disorders. FUTURE WORK We describe proof-of-principle randomised controlled trials that could better inform the case for screening using ultrasound in late pregnancy. STUDY REGISTRATION This study is registered as PROSPERO CRD42017064093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gordon Cs Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - David Wastlund
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Aris Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - Julia Sanders
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Alexander Ep Heazell
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Stephen C Robson
- Reproductive and Vascular Biology Group, The Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Edward Cf Wilson
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
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12
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Sherrell HC, Clifton VL, Kumar S. Prelabor screening at term using the cerebroplacental ratio and placental growth factor: a pragmatic randomized open-label phase 2 trial. Am J Obstet Gynecol 2020; 223:429.e1-429.e9. [PMID: 32112730 DOI: 10.1016/j.ajog.2020.02.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/27/2020] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND OBJECTIVE In some women placental function may not be adequate to meet fetal growth requirements in late pregnancy or the additional demands during labor, thus predisposing these infants to intrapartum fetal compromise and subsequent serious morbidity and mortality. The objective of this study was to determine if the introduction of a prelabor screening test at term combining the cerebroplacental ratio and maternal placental growth factor level would result in a reduction in a composite of adverse outcomes. STUDY DESIGN Single-site, nonblinded, randomized controlled trial conducted at a tertiary hospital in Brisbane, Australia. Eligible women were randomized to either receive the screening test performed between 37-38 weeks or routine obstetric care. Screen-positive women were offered induction of labor. The primary outcome was a composite of emergency cesarean delivery for nonreassuring fetal status (fetal distress) or severe neonatal acidosis or low Apgar score or stillbirth or neonatal death. RESULTS Women were recruited and randomized (n = 501) between April 2017 and January 2019. Sixty-three of 249 subjects (25.3%) in the screened group compared to 56 of 252 (22.2%) in the control group experienced the primary outcome (relative risk = 1.14 [95% confidence interval, 0.83-1.56]; P = .418). Women who screened positive were more likely to require operative delivery for fetal distress, have meconium-stained liquor, have pathologic fetal heart rate abnormalities, and have infants with lower birthweight compared to women that screened negative. CONCLUSION The introduction of this test did not result in improvements in intrapartum intervention rates or neonatal outcomes. However, it did show discriminatory potential, and future research should focus on refining the thresholds used.
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13
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Smith G. A critical review of the Cochrane meta-analysis of routine late-pregnancy ultrasound. BJOG 2020; 128:207-213. [PMID: 32598533 DOI: 10.1111/1471-0528.16386] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2020] [Indexed: 11/29/2022]
Abstract
A Cochrane review of universal late-pregnancy ultrasound has been highly influential in guiding UK practice, concluding that it does not improve outcome. However, the meta-analysis combines trials that used diverse definitions of screen positive, were designed in the absence of high-quality data on diagnostic effectiveness and did not couple screening to an effective intervention. Moreover, even if the trials had combined a highly effective screening test with a highly effective intervention, the sample size was 15% of that required to study perinatal death. It is not known whether universal late-pregnancy ultrasound confers benefit on the mother or baby. TWEETABLE ABSTRACT: Despite >50 years of research, we do not know whether universal late-pregnancy ultrasound confers benefit on the mother or baby.
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Affiliation(s)
- Gcs Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
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14
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A maternal serum metabolite ratio predicts fetal growth restriction at term. Nat Med 2020; 26:348-353. [PMID: 32161413 DOI: 10.1038/s41591-020-0804-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 01/30/2020] [Indexed: 11/08/2022]
Abstract
Fetal growth restriction (FGR) is the major single cause of stillbirth1 and is also associated with neonatal morbidity and mortality2,3, impaired health and educational achievement in childhood4,5 and with a range of diseases in later life6. Effective screening and intervention for FGR is an unmet clinical need. Here, we performed ultrahigh performance liquid chromatography-tandem mass spectroscopy (UPLC-MS/MS) metabolomics on maternal serum at 12, 20 and 28 weeks of gestational age (wkGA) using 175 cases of term FGR and 299 controls from the Pregnancy Outcome Prediction (POP) study, conducted in Cambridge, UK, to identify predictive metabolites. Internal validation using 36 wkGA samples demonstrated that a ratio of the products of the relative concentrations of two positively associated metabolites (1-(1-enyl-stearoyl)-2-oleoyl-GPC (P-18:0/18:1) and 1,5-anhydroglucitol) to the product of the relative concentrations of two negatively associated metabolites (5α-androstan-3α,17α-diol disulfate and N1,N12-diacetylspermine) predicted FGR at term. The ratio had approximately double the discrimination as compared to a previously developed angiogenic biomarker7, the soluble fms-like tyrosine kinase 1:placental growth factor (sFLT1:PlGF) ratio (AUC 0.78 versus 0.64, P = 0.0001). We validated the predictive performance of the metabolite ratio in two sub-samples of a demographically dissimilar cohort, Born in Bradford (BiB), conducted in Bradford, UK (P = 0.0002). Screening and intervention using this metabolite ratio in conjunction with ultrasonic imaging at around 36 wkGA could plausibly prevent adverse events through enhanced fetal monitoring and targeted induction of labor.
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15
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Hwang IW, Kang YD, Kwon BN, Hong JH, Han SH, Kim JS, Park JW, Jin HJ. Genetic variations of MTHFR gene and their association with preterm birth in Korean women. Medicina (B Aires) 2019; 53:380-385. [PMID: 29428336 DOI: 10.1016/j.medici.2018.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/05/2017] [Accepted: 01/16/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The MTHFR gene encodes the methylenetetrahydrofolate reductase known to be involved in the homocysteine-methionine pathway. It has been reported that the deficiency of MTHFR activity may cause hyperhomocysteinemia which results in adverse pregnancy outcomes. Previous studies reported a correlation between the MTHFR gene polymorphisms (677 T/C and 1298 A/C) and lower MTHFR activity and its association with preterm birth in various populations. Since these results were conflicting, we analyzed the genetic association of MTHFR gene 677 T/C and 1298 A/C polymorphisms with preterm birth in Korean women. MATERIALS AND METHODS The subjects for case-control study were collected a total of 226 Korean women (98 preterm-birth patients and 128 controls). Genotype frequency differences between the case and the control were assessed using chi-square tests. Mann-Whitney t-test was used to estimate the effects of 1298 A/C genotype on clinicopathological characteristics (systolic blood pressure, diastolic blood pressure, birth weight, and gestational age at delivery) in preterm-birth patients. RESULTS Our results showed that the MTHFR 677 C/T polymorphism was significantly associated with preterm-birth patients in the analysis of genotype frequency (P=0.044) and the over-dominant model (OR=0.54; 95% CI, 0.320-0.920; P=0.023). The recessive model showed a marginal trend toward significance (OR=0.47; 95% CI, 0.220-1.010; P=0.046). The 1298 A/C polymorphism was also associated with reduced preterm-birth risk in the recessive model (P=0.032). In the correlation analysis, the 1298 C allele was significantly associated with increasing of gestational age at delivery in preterm-birth patients (P=0.034). CONCLUSIONS Our findings suggested that the MTHFR gene 677 C/T and 1298 A/C polymorphisms might have protective effects for preterm birth in the Korean women.
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Affiliation(s)
- In Wook Hwang
- Department of Biological Sciences, College of Natural Science, Dankook University, Cheonan, Republic of Korea
| | - Yun Dan Kang
- Department of Obstetrics and Gynecology, Dankook University Hospital, Cheonan, Republic of Korea
| | - Bit Na Kwon
- Department of Biological Sciences, College of Natural Science, Dankook University, Cheonan, Republic of Korea
| | - Jun Ho Hong
- Department of Biological Sciences, College of Natural Science, Dankook University, Cheonan, Republic of Korea
| | - Seung Hun Han
- Department of Microbiology, College of Natural Science, Dankook University, Cheonan, Republic of Korea
| | - Jong Soo Kim
- Department of Obstetrics and Gynecology, Dankook University Hospital, Cheonan, Republic of Korea
| | - Jin Wan Park
- Department of Obstetrics and Gynecology, Dankook University Hospital, Cheonan, Republic of Korea.
| | - Han Jun Jin
- Department of Biological Sciences, College of Natural Science, Dankook University, Cheonan, Republic of Korea.
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Higgins LE, Myers JE, Sibley CP, Johnstone ED, Heazell AEP. Antenatal placental assessment in the prediction of adverse pregnancy outcome after reduced fetal movement. PLoS One 2018; 13:e0206533. [PMID: 30395584 PMCID: PMC6218043 DOI: 10.1371/journal.pone.0206533] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 10/15/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To assess the value of in utero placental assessment in predicting adverse pregnancy outcome after reported reduced fetal movements (RFM). METHOD A non-interventional prospective cohort study of women (N = 300) with subjective RFM at ≥28 weeks' gestation in singleton non-anomalous pregnancies at a UK tertiary maternity hospital. Clinical, sonographic (fetal weight, placental size and maternal, fetal and placental arterial Doppler) and biochemical (maternal serum hCG, hPL, progesterone, PlGF and sFlt-1) assessment was conducted. Multiple logistic regression identified combinations of measurements (models) most predictive of adverse pregnancy outcome (perinatal mortality, birth weight <10th centile, five minute Apgar score <7, umbilical arterial pH <7.1 or base excess <-10, neonatal intensive care admission). Models were compared by test performance characteristics (ROC curve, sensitivity, specificity, positive/negative predictive value, positive/negative likelihood ratios) against baseline care (estimated fetal weight centile, amniotic fluid index and gestation at presentation). RESULTS 61 (20.6%) pregnancies ended in adverse outcome. Models incorporating PlGF/sFlt-1 ratio and umbilical artery free loop Doppler impedance demonstrated modest improvement in ROC area for adverse outcome (baseline care 0.69 vs. proposed models 0.73-0.76, p<0.05). However, there was little improvement in other test characteristics (baseline vs. best proposed model: sensitivity 21.7% [95% confidence interval 13.1-33.6] vs. 35.8%% [24.4-49.3], specificity 96.6% [93.4-98.3] vs. 94.7% [90.7-97.0], PPV 61.9% [40.9-79.3] vs. 63.3% [45.5-78.1], NPV 82.8% [77.9-86.8] vs. 85.2% [80.0-89.2], positive LR 6.3 [2.8-14.6] vs. 6.7 [3.4-3.3], negative LR 0.81 [0.71-0.93] vs. 0.68 [0.55-0.83]) and wide confidence intervals. Negative post-test probability remained high (16.7% vs. 14.0%). CONCLUSION Antenatal placental assessment may improve identification of RFM pregnancies at highest risk of adverse pregnancy outcome but further work is required to understand and refine currently available outcome definitions and diagnostic techniques to improve clinical utility.
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Affiliation(s)
- Lucy E. Higgins
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jenny E. Myers
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Colin P. Sibley
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Edward D. Johnstone
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Alexander E. P. Heazell
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
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17
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Smith GC. Universal screening for foetal growth restriction. Best Pract Res Clin Obstet Gynaecol 2018; 49:16-28. [DOI: 10.1016/j.bpobgyn.2018.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 02/15/2018] [Indexed: 12/22/2022]
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18
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Gaccioli F, Aye ILMH, Sovio U, Charnock-Jones DS, Smith GCS. Screening for fetal growth restriction using fetal biometry combined with maternal biomarkers. Am J Obstet Gynecol 2018; 218:S725-S737. [PMID: 29275822 DOI: 10.1016/j.ajog.2017.12.002] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/24/2017] [Accepted: 12/01/2017] [Indexed: 12/31/2022]
Abstract
Fetal growth restriction is a major determinant of perinatal morbidity and mortality. Screening for fetal growth restriction is a key element of prenatal care but it is recognized to be problematic. Screening using clinical risk assessment and targeting ultrasound to high-risk women is the standard of care in the United States and United Kingdom, but the approach is known to have low sensitivity. Systematic reviews of randomized controlled trials do not demonstrate any benefit from universal ultrasound screening for fetal growth restriction in the third trimester, but the evidence base is not strong. Implementation of universal ultrasound screening in low-risk women in France failed to reduce the risk of complications among small-for-gestational-age infants but did appear to cause iatrogenic harm to false positives. One strategy to making progress is to improve screening by developing more sensitive and specific tests with the key goal of differentiating between healthy small fetuses and those that are small through fetal growth restriction. As abnormal placentation is thought to be the major cause of fetal growth restriction, one approach is to combine fetal biometry with an indicator of placental dysfunction. In the past, these indicators were generally ultrasonic measurements, such as Doppler flow velocimetry of the uteroplacental circulation. However, another promising approach is to combine ultrasonic suspicion of small-for-gestational-age infant with a blood test indicating placental dysfunction. Thus far, much of the research on maternal serum biomarkers for fetal growth restriction has involved the secondary analysis of tests performed for other indications, such as fetal aneuploidies. An exemplar of this is pregnancy-associated plasma protein A. This blood test is performed primarily to assess the risk of Down syndrome, but women with low first-trimester levels are now serially scanned in later pregnancy due to associations with placental causes of stillbirth, including fetal growth restriction. The development of "omic" technologies presents a huge opportunity to identify novel biomarkers for fetal growth restriction. The hope is that when such markers are measured alongside ultrasonic fetal biometry, the combination would have strong predictive power for fetal growth restriction and its related complications. However, a series of important methodological considerations in assessing the diagnostic effectiveness of new tests will have to be addressed. The challenge thereafter will be to identify novel disease-modifying interventions, which are the essential partner to an effective screening test to achieve clinically effective population-based screening.
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Affiliation(s)
- Francesca Gaccioli
- Department of Obstetrics and Gynaecology, National Institute for Health Research Cambridge Comprehensive Biomedical Research Center, and Center for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Irving L M H Aye
- Department of Obstetrics and Gynaecology, National Institute for Health Research Cambridge Comprehensive Biomedical Research Center, and Center for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, National Institute for Health Research Cambridge Comprehensive Biomedical Research Center, and Center for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - D Stephen Charnock-Jones
- Department of Obstetrics and Gynaecology, National Institute for Health Research Cambridge Comprehensive Biomedical Research Center, and Center for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, National Institute for Health Research Cambridge Comprehensive Biomedical Research Center, and Center for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom.
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19
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The pregnancy outcome prediction (POP) study: Investigating the relationship between serial prenatal ultrasonography, biomarkers, placental phenotype and adverse pregnancy outcomes. Placenta 2017. [PMCID: PMC5701771 DOI: 10.1016/j.placenta.2016.10.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Placental dysfunction is implicated in many major complications of pregnancy associated with adverse maternal and infant outcome, such as preeclampsia, fetal growth restriction and stillbirth. Yet, despite years of intensive research, screening for these complications is still largely based upon clinical grounds rather than ultrasonic and/or biochemical assessment of placental function. One of the few widely employed methods for assessment of risk, low first trimester levels of PAPP-A (Pregnancy Associated Plasma Protein A), was identified through secondary analysis of data collected to identify new methods of screening for Down's syndrome rather than as a purposeful search for screening tests for abnormal placentation. Development of improved methods for population screening requires better mechanistic understanding of the pathways leading to placentally-related complications of human pregnancy. This is in addition to a need for identification of biomarkers which reflect the underlying pathology, while predicting associated disease with high sensitivity and specificity. In this paper, we outline some of the challenges and opportunities in this area. Furthermore, we illustrate how some of these can be addressed in research studies using the example of the Pregnancy Outcome Prediction (POP) study, a prospective cohort study conducted in Cambridge, UK.
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20
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Lindsay RS, Mackin ST, Nelson SM. Gestational diabetes mellitus-right person, right treatment, right time? BMC Med 2017; 15:163. [PMID: 28844206 PMCID: PMC5572161 DOI: 10.1186/s12916-017-0925-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/09/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Personalised treatment that is uniquely tailored to an individual's phenotype has become a key goal of clinical and pharmaceutical development across many, particularly chronic, diseases. For type 2 diabetes, the importance of the underlying clinical heterogeneity of the condition is emphasised and a range of treatments are now available, with personalised approaches being developed. While a close connection between risk factors for type 2 diabetes and gestational diabetes has long been acknowledged, stratification of screening, treatment and obstetric intervention remains in its infancy. CONCLUSIONS Although there have been major advances in our understanding of glucose tolerance in pregnancy and of the benefits of treatment of gestational diabetes, we argue that far more vigorous approaches are needed to enable development of companion diagnostics, and to ensure the efficacious and safe use of novel therapeutic agents and strategies to improve outcomes in this common condition.
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Affiliation(s)
- Robert S Lindsay
- Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, University Place, Glasgow, G12 8TA, UK.
| | - Sharon T Mackin
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Scott M Nelson
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
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21
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Sovio U, Gaccioli F, Cook E, Hund M, Charnock-Jones DS, Smith GCS. Prediction of Preeclampsia Using the Soluble fms-Like Tyrosine Kinase 1 to Placental Growth Factor Ratio: A Prospective Cohort Study of Unselected Nulliparous Women. Hypertension 2017; 69:731-738. [PMID: 28167687 PMCID: PMC5344177 DOI: 10.1161/hypertensionaha.116.08620] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 11/09/2016] [Accepted: 12/15/2016] [Indexed: 01/23/2023]
Abstract
We sought to assess the ratio of sFlt-1 (soluble fms-like tyrosine kinase 1) to PlGF (placental growth factor) in maternal serum as a screening test for preeclampsia in unselected nulliparous women with a singleton pregnancy. We studied 4099 women recruited to the POP study (Pregnancy Outcome Prediction) (Cambridge, United Kingdom). The sFlt-1:PlGF ratio was measured using the Roche Cobas e411 platform at ≈20, ≈28, and ≈36 weeks of gestational age (wkGA). Screen positive was defined as an sFlt-1:PlGF ratio >38, but higher thresholds were also studied. At 28 wkGA, an sFlt-1:PlGF ratio >38 had a positive predictive value (PPV) of 32% for preeclampsia and preterm birth, and the PPV was similar comparing women with low and high prior risk of disease. At 36 wkGA, an sFlt-1:PlGF ratio >38 had a PPV for severe preeclampsia of 20% in high-risk women and 6.4% in low-risk women. At 36 wkGA, an sFlt-1:PlGF ratio >110 had a PPV of 30% for severe preeclampsia, and the PPV was similar comparing low- and high-risk women. Overall, at 36 wkGA, 195 (5.2%) women either had an sFlt-1:PlGF ratio of >110 or an sFlt-1:PlGF ratio >38 plus maternal risk factors: 43% of these women developed preeclampsia, about half with severe features. Among low-risk women at 36 wkGA, an sFlt-1:PlGF ratio ≤38 had a negative predictive value for severe preeclampsia of 99.2%. The sFlt-1:PlGF ratio provided clinically useful prediction of the risk of the most important manifestations of preeclampsia in a cohort of unselected nulliparous women.
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Affiliation(s)
- Ulla Sovio
- From the Department of Obstetrics and Gynaecology, University of Cambridge, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); NIHR (National Institute for Health Research) Cambridge Comprehensive Biomedical Research Centre, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); and Roche Diagnostics International, Rotkreuz, Switzerland (M.H.).
| | - Francesca Gaccioli
- From the Department of Obstetrics and Gynaecology, University of Cambridge, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); NIHR (National Institute for Health Research) Cambridge Comprehensive Biomedical Research Centre, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); and Roche Diagnostics International, Rotkreuz, Switzerland (M.H.)
| | - Emma Cook
- From the Department of Obstetrics and Gynaecology, University of Cambridge, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); NIHR (National Institute for Health Research) Cambridge Comprehensive Biomedical Research Centre, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); and Roche Diagnostics International, Rotkreuz, Switzerland (M.H.)
| | - Martin Hund
- From the Department of Obstetrics and Gynaecology, University of Cambridge, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); NIHR (National Institute for Health Research) Cambridge Comprehensive Biomedical Research Centre, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); and Roche Diagnostics International, Rotkreuz, Switzerland (M.H.)
| | - D Stephen Charnock-Jones
- From the Department of Obstetrics and Gynaecology, University of Cambridge, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); NIHR (National Institute for Health Research) Cambridge Comprehensive Biomedical Research Centre, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); and Roche Diagnostics International, Rotkreuz, Switzerland (M.H.)
| | - Gordon C S Smith
- From the Department of Obstetrics and Gynaecology, University of Cambridge, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); NIHR (National Institute for Health Research) Cambridge Comprehensive Biomedical Research Centre, United Kingdom (U.S., F.G., E.C., D.S.C.-J., G.C.S.S.); and Roche Diagnostics International, Rotkreuz, Switzerland (M.H.)
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Cleaton MAM, Dent CL, Howard M, Corish JA, Gutteridge I, Sovio U, Gaccioli F, Takahashi N, Bauer SR, Charnock-Jones DS, Powell TL, Smith GCS, Ferguson-Smith AC, Charalambous M. Fetus-derived DLK1 is required for maternal metabolic adaptations to pregnancy and is associated with fetal growth restriction. Nat Genet 2016; 48:1473-1480. [PMID: 27776119 DOI: 10.1038/ng.3699] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 09/23/2016] [Indexed: 01/16/2023]
Abstract
Pregnancy is a state of high metabolic demand. Fasting diverts metabolism to fatty acid oxidation, and the fasted response occurs much more rapidly in pregnant women than in non-pregnant women. The product of the imprinted DLK1 gene (delta-like homolog 1) is an endocrine signaling molecule that reaches a high concentration in the maternal circulation during late pregnancy. By using mouse models with deleted Dlk1, we show that the fetus is the source of maternal circulating DLK1. In the absence of fetally derived DLK1, the maternal fasting response is impaired. Furthermore, we found that maternal circulating DLK1 levels predict embryonic mass in mice and can differentiate healthy small-for-gestational-age (SGA) infants from pathologically small infants in a human cohort. Therefore, measurement of DLK1 concentration in maternal blood may be a valuable method for diagnosing human disorders associated with impaired DLK1 expression and to predict poor intrauterine growth and complications of pregnancy.
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Affiliation(s)
- Mary A M Cleaton
- Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Claire L Dent
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Howard
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | | | - Ulla Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge and NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| | - Francesca Gaccioli
- Department of Obstetrics and Gynaecology, University of Cambridge and NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| | | | - Steven R Bauer
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Bethesda, Maryland, USA
| | - D Steven Charnock-Jones
- Department of Obstetrics and Gynaecology, University of Cambridge and NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| | - Theresa L Powell
- Department of Pediatrics, Section for Neonatology, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge and NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| | - Anne C Ferguson-Smith
- Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK.,Department of Genetics, University of Cambridge, Cambridge, UK
| | - Marika Charalambous
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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23
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Smith GCS. Screening and prevention of stillbirth. Best Pract Res Clin Obstet Gynaecol 2016; 38:71-82. [PMID: 27729208 DOI: 10.1016/j.bpobgyn.2016.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/26/2016] [Accepted: 08/30/2016] [Indexed: 10/21/2022]
Abstract
Stillbirth is delivery of a baby at or after 24 weeks of gestational age (UK definition) not showing any signs of life. It affects almost one in 200 pregnancies and is the single major cause of perinatal death. Stillbirth is associated with a wide range of maternal demographic characteristics, but most of the variations in stillbirth risk are independent of these characteristics. Stillbirth is the end point of multiple processes, but the single most common cause is probably placental dysfunction. Stillbirth is associated with a wide range of biochemical and ultrasonic predictors, but there is limited evidence to support population-based screening. However, the evidence based is weak due to the use of poorly characterised screening tests, the failure to couple risk assessment with a clearly effective intervention for those who screen positive and inadequate study sample sizes. Basic research needs to identify better predictors, and clinical trials need to adopt more rigorous methodologies.
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Affiliation(s)
- Gordon C S Smith
- Professor & Head of the Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, CB2 0SW, UK.
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24
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Kane SC. First trimester screening for pre-eclampsia. Obstet Med 2016; 9:106-12. [PMID: 27630745 DOI: 10.1177/1753495x16649074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 04/18/2016] [Indexed: 11/17/2022] Open
Abstract
The commercial availability of tests in the first trimester of pregnancy that predict the later development of pre-eclampsia has prompted considerable debate regarding their clinical utility and the degree to which they fulfil the longstanding principles of screening. Such tests have been shown to achieve detection rates for early pre-eclampsia (requiring delivery prior to 34 weeks) of over 90%, for a false positive rate of 10%. However, their capacity to predict later onset pre-eclampsia, which accounts for the bulk of the disease burden, is much more limited. The relatively few studies validating the performance of these tests in different populations have demonstrated significant variations in performance. Moreover, prospective research confirming that the administration of aspirin to those screened to be high risk reduces the incidence of pre-eclampsia is yet to be completed, and there may be harms in restricting aspirin therapy to this group, given its broader beneficial effect. In light of these limitations, further development of these tests is recommended prior to their introduction to clinical practice.
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Affiliation(s)
- Stefan C Kane
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Pregnancy Research Centre, Department of Maternal-Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia
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25
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Sovio U, White IR, Dacey A, Pasupathy D, Smith GCS. Screening for fetal growth restriction with universal third trimester ultrasonography in nulliparous women in the Pregnancy Outcome Prediction (POP) study: a prospective cohort study. Lancet 2015; 386:2089-2097. [PMID: 26360240 PMCID: PMC4655320 DOI: 10.1016/s0140-6736(15)00131-2] [Citation(s) in RCA: 404] [Impact Index Per Article: 44.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fetal growth restriction is a major determinant of adverse perinatal outcome. Screening procedures for fetal growth restriction need to identify small babies and then differentiate between those that are healthy and those that are pathologically small. We sought to determine the diagnostic effectiveness of universal ultrasonic fetal biometry in the third trimester as a screening test for small-for-gestational-age (SGA) infants, and whether the risk of morbidity associated with being small differed in the presence or absence of ultrasonic markers of fetal growth restriction. METHODS The Pregnancy Outcome Prediction (POP) study was a prospective cohort study of nulliparous women with a viable singleton pregnancy at the time of the dating ultrasound scan. Women participating had clinically indicated ultrasonography in the third trimester as per routine clinical care and these results were reported as usual (selective ultrasonography). Additionally, all participants had research ultrasonography, including fetal biometry at 28 and 36 weeks' gestational age. These results were not made available to participants or treating clinicians (universal ultrasonography). We regarded SGA as a birthweight of less than the 10th percentile for gestational age and screen positive for SGA an ultrasonographic estimated fetal weight of less than the 10th percentile for gestational age. Markers of fetal growth restriction included biometric ratios, utero-placental Doppler, and fetal growth velocity. We assessed outcomes for consenting participants who attended research scans and had a livebirth at the Rosie Hospital (Cambridge, UK) after the 28 weeks' research scan. FINDINGS Between Jan 14, 2008, and July 31, 2012, 4512 women provided written informed consent of whom 3977 (88%) were eligible for analysis. Sensitivity for detection of SGA infants was 20% (95% CI 15-24; 69 of 352 fetuses) for selective ultrasonography and 57% (51-62; 199 of 352 fetuses) for universal ultrasonography (relative sensitivity 2·9, 95% CI 2·4-3·5, p<0·0001). Of the 3977 fetuses, 562 (14·1%) were identified by universal ultrasonography with an estimated fetal weight of less than the 10th percentile and were at an increased risk of neonatal morbidity (relative risk [RR] 1·60, 95% CI 1·22-2·09, p=0·0012). However, estimated fetal weight of less than the 10th percentile was only associated with the risk of neonatal morbidity (pinteraction=0·005) if the fetal abdominal circumference growth velocity was in the lowest decile (RR 3·9, 95% CI 1·9-8·1, p=0·0001). 172 (4%) of 3977 pregnancies had both an estimated fetal weight of less than the 10th percentile and abdominal circumference growth velocity in the lowest decile, and had a relative risk of delivering an SGA infant with neonatal morbidity of 17·6 (9·2-34·0, p<0·0001). INTERPRETATION Screening of nulliparous women with universal third trimester fetal biometry roughly tripled detection of SGA infants. Combined analysis of fetal biometry and fetal growth velocity identified a subset of SGA fetuses that were at increased risk of neonatal morbidity. FUNDING National Institute for Health Research, Medical Research Council, Sands, and GE Healthcare.
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Affiliation(s)
- Ulla Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| | - Ian R White
- Medical Research Council Biostatistics Unit, Institute of Public Health, Cambridge, UK
| | - Alison Dacey
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| | - Dharmintra Pasupathy
- Division of Women's Health, Women's Health Academic Centre, King's Health Partners, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK.
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26
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Chen J, Chen L, Zhu LH, Zhang ST, Wu YL. Association of methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism with preterm delivery and placental abruption: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2015; 95:157-65. [PMID: 26439908 DOI: 10.1111/aogs.12789] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 09/20/2015] [Indexed: 01/07/2023]
Affiliation(s)
- Jian Chen
- Medical Department; Ningbo Women and Children's Hospital; Ningbo Zhejiang China
| | - Liang Chen
- Department of Obstetrics and Gynecology; Ningbo Women and Children's Hospital; Ningbo Zhejiang China
| | - Li-Hua Zhu
- Medical Department; Ningbo Women and Children's Hospital; Ningbo Zhejiang China
| | - Si-Tong Zhang
- Department of Obstetrics and Gynecology; Ningbo Women and Children's Hospital; Ningbo Zhejiang China
| | - Yi-Le Wu
- Department of Epidemiology and Statistics; School of Public Health; Anhui Medical University; Hefei Anhui China
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27
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Affiliation(s)
- Gordon CS Smith
- Department of Obstetrics and Gynaecology; University of Cambridge; Box 223, The Rosie Hospital, Robinson Way Cambridge CB2 2SW UK
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28
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Higgins LE, Rey de Castro N, Addo N, Wareing M, Greenwood SL, Jones RL, Sibley CP, Johnstone ED, Heazell AEP. Placental Features of Late-Onset Adverse Pregnancy Outcome. PLoS One 2015; 10:e0129117. [PMID: 26120838 PMCID: PMC4488264 DOI: 10.1371/journal.pone.0129117] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/05/2015] [Indexed: 12/12/2022] Open
Abstract
Objective Currently, no investigations reliably identify placental dysfunction in late pregnancy. To facilitate the development of such investigations we aimed to identify placental features that differ between normal and adverse outcome in late pregnancy in a group of pregnancies with reduced fetal movement. Methods Following third trimester presentation with reduced fetal movement (N = 100), placental structure ex vivo was measured. Placental function was then assessed in terms of (i) chorionic plate artery agonist responses and length-tension characteristics using wire myography and (ii) production and release of placentally derived hormones (by quantitative polymerase chain reaction and enzyme linked immunosorbant assay of villous tissue and explant conditioned culture medium). Results Placentas from pregnancies ending in adverse outcome (N = 23) were ~25% smaller in weight, volume, length, width and disc area (all p<0.0001) compared with those from normal outcome pregnancies. Villous and trophoblast areas were unchanged, but villous vascularity was reduced (median (interquartile range): adverse outcome 10 (10–12) vessels/mm2 vs. normal outcome 13 (12–15), p = 0.002). Adverse outcome pregnancy placental arteries were relatively insensitive to nitric oxide donated by sodium nitroprusside compared to normal outcome pregnancy placental arteries (50% Effective Concentration 30 (19–50) nM vs. 12 (6–24), p = 0.02). Adverse outcome pregnancy placental tissue contained less human chorionic gonadotrophin (20 (11–50) vs. 55 (24–102) mIU/mg, p = 0.007) and human placental lactogen (11 (6–14) vs. 27 (9–50) mg/mg, p = 0.006) and released more soluble fms-like tyrosine kinase-1 (21 (13–29) vs. 5 (2–15) ng/mg, p = 0.01) compared with normal outcome pregnancy placental tissue. Conclusion These data provide a description of the placental phenotype of adverse outcome in late pregnancy. Antenatal tests that accurately reflect elements of this phenotype may improve its prediction.
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Affiliation(s)
- Lucy E. Higgins
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, M13 9WL, United Kingdom
- Maternal and Fetal Health Research Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
- * E-mail:
| | - Nicolas Rey de Castro
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, M13 9WL, United Kingdom
- Maternal and Fetal Health Research Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Naa Addo
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, M13 9WL, United Kingdom
- Maternal and Fetal Health Research Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Mark Wareing
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, M13 9WL, United Kingdom
- Maternal and Fetal Health Research Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Susan L. Greenwood
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, M13 9WL, United Kingdom
- Maternal and Fetal Health Research Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Rebecca L. Jones
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, M13 9WL, United Kingdom
- Maternal and Fetal Health Research Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Colin P. Sibley
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, M13 9WL, United Kingdom
- Maternal and Fetal Health Research Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Edward D. Johnstone
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, M13 9WL, United Kingdom
- Maternal and Fetal Health Research Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Alexander E. P. Heazell
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, M13 9WL, United Kingdom
- Maternal and Fetal Health Research Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
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29
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Brunelli VB, Prefumo F. Quality of first trimester risk prediction models for pre-eclampsia: a systematic review. BJOG 2015; 122:904-14. [DOI: 10.1111/1471-0528.13334] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2015] [Indexed: 12/12/2022]
Affiliation(s)
- VB Brunelli
- Department of Obstetrics and Gynaecology; University of Brescia; Brescia Italy
| | - F Prefumo
- Department of Obstetrics and Gynaecology; University of Brescia; Brescia Italy
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30
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Kenny LC, Black MA, Poston L, Taylor R, Myers JE, Baker PN, McCowan LM, Simpson NAB, Dekker GA, Roberts CT, Rodems K, Noland B, Raymundo M, Walker JJ, North RA. Early pregnancy prediction of preeclampsia in nulliparous women, combining clinical risk and biomarkers: the Screening for Pregnancy Endpoints (SCOPE) international cohort study. Hypertension 2014; 64:644-52. [PMID: 25122928 DOI: 10.1161/hypertensionaha.114.03578] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
More than half of all cases of preeclampsia occur in healthy first-time pregnant women. Our aim was to develop a method to predict those at risk by combining clinical factors and measurements of biomarkers in women recruited to the Screening for Pregnancy Endpoints (SCOPE) study of low-risk nulliparous women. Forty-seven biomarkers identified on the basis of (1) association with preeclampsia, (2) a biological role in placentation, or (3) a role in cellular mechanisms involved in the pathogenesis of preeclampsia were measured in plasma sampled at 14 to 16 weeks' gestation from 5623 women. The cohort was randomly divided into training (n=3747) and validation (n=1876) cohorts. Preeclampsia developed in 278 (4.9%) women, of whom 28 (0.5%) developed early-onset preeclampsia. The final model for the prediction of preeclampsia included placental growth factor, mean arterial pressure, and body mass index at 14 to 16 weeks' gestation, the consumption of ≥3 pieces of fruit per day, and mean uterine artery resistance index. The area under the receiver operator curve (95% confidence interval) for this model in training and validation cohorts was 0.73 (0.70-0.77) and 0.68 (0.63-0.74), respectively. A predictive model of early-onset preeclampsia included angiogenin/placental growth factor as a ratio, mean arterial pressure, any pregnancy loss <10 weeks, and mean uterine artery resistance index (area under the receiver operator curve [95% confidence interval] in training and validation cohorts, 0.89 [0.78-1.0] and 0.78 [0.58-0.99], respectively). Neither model included pregnancy-associated plasma protein A, previously reported to predict preeclampsia in populations of mixed parity and risk. In nulliparous women, combining multiple biomarkers and clinical data provided modest prediction of preeclampsia.
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Affiliation(s)
- Louise C Kenny
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.).
| | - Michael A Black
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Lucilla Poston
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Rennae Taylor
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Jenny E Myers
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Philip N Baker
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Lesley M McCowan
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Nigel A B Simpson
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Gus A Dekker
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Claire T Roberts
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Kelline Rodems
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Brian Noland
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Michael Raymundo
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - James J Walker
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
| | - Robyn A North
- From the Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (L.C.K.); Department of Biochemistry, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand (M.A.B.); Division of Women's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, United Kingdom (L.P., R.A.N.); Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences (R.T., P.N.B., L.M.M.), National Centre for Growth and Development and Maternal and Fetal Health, Liggins Institute (P.N.B.), and South Auckland Clinical School, Faculty of Medical and Health Sciences (L.M.M.), University of Auckland, Auckland, New Zealand; Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester, United Kingdom (J.E.M.); Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand (P.N.B.); Section of Obstetrics and Gynaecology, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom (N.A.B.S., J.J.W.); The Women's and Children's Division, Lyell McEwin Hospital (G.A.D., C.T.R.) and School of Paediatrics and Reproductive Health, Robinson Institute (G.A.D., C.T.R.), University of Adelaide, Adelaide, South Australia; and Alere Discovery, San Diego, CA (K.R., B.N., M.R.)
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Moraitis AA, Wood AM, Fleming M, Smith GCS. Birth weight percentile and the risk of term perinatal death. Obstet Gynecol 2014; 124:274-283. [PMID: 25004344 DOI: 10.1097/aog.0000000000000388] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the association between birth weight percentile and the risk of perinatal death at term in relation to the cause of death. METHODS We performed a retrospective cohort study of all term singleton births in delivery units in Scotland between 1992 and 2008 (n=784,576), excluding perinatal deaths ascribed to congenital anomaly. RESULTS There were 1,700 perinatal deaths in the cohort, which were not the result of congenital anomaly (21.7/10,000 women at term). We observed a reversed J-shaped association between birth weight percentile and the risk of antepartum stillbirth in all women, but the associations significantly differed (P<.001) according to smoking status. The highest risk (adjusted odds ratio referent to 21st-80th percentile, 95% confidence interval) among nonsmokers was for birth weight third or less percentile (10.5, 8.2-13.3), but there were also positive associations for birth weight percentiles 4th-10th (3.8, 3.0-4.8), 11th-20th (1.9, 1.5-2.4), and 98th-100th (1.8, 1.3-2.4). Among smokers, the associations with being small were weaker and the associations with being large were stronger. We also observed a reversed J-shaped association between birth weight percentile and the risk of delivery-related perinatal death (ie, intrapartum stillbirth or neonatal death), but there was no interaction with smoking. The highest risk was for birth weight greater than the 97th percentile (2.3, 1.6-3.3), but there were also associations with third or less percentile (2.1, 1.4-3.1), 4th-10th (1.8, 1.4-2.4), and 11th-20th (1.5, 1.2-2.0). Analysis of the attributable fraction indicated that approximately one in three antepartum stillbirths and one in six delivery-related deaths at term could be related to birth weight percentile outside the range 21st-97th percentile. CONCLUSION Effective detection of variation in fetal size at term has potential as a screening test for the risk of perinatal death. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Alexandros A Moraitis
- Departments of Obstetrics and Gynaecology and Public Health and Primary Care, University of Cambridge, and the National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre, Cambridge, and the Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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Conde-Agudelo A, Bird S, Kennedy SH, Villar J, Papageorghiou AT. First- and second-trimester tests to predict stillbirth in unselected pregnant women: a systematic review and meta-analysis. BJOG 2014; 122:41-55. [PMID: 25236870 DOI: 10.1111/1471-0528.13096] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several biophysical and biochemical tests have been proposed to predict stillbirth but their predictive ability remains unclear. OBJECTIVE To assess the accuracy of tests performed during the first and/or second trimester of pregnancy to predict stillbirth in unselected women with singleton, structurally and chromosomally normal fetuses through use of formal methods for systematic reviews and meta-analytic techniques. SEARCH STRATEGY Electronic databases, bibliographies and conference proceedings. SELECTION CRITERIA Observational studies that evaluated the predictive accuracy for stillbirth of tests performed during the first two trimesters of pregnancy. DATA COLLECTION AND ANALYSIS Two reviewers selected studies, assessed risk of bias and extracted data. Summary receiver operating characteristic curves, pooled sensitivities, specificities and likelihood ratios (LRs) were generated. Data were synthesised separately for stillbirth as a sole category and for specific stillbirth categories. MAIN RESULTS Seventy-one studies, evaluating 16 single and five combined tests, met the inclusion criteria. A uterine artery pulsatility index >90th centile during the second trimester and low levels of pregnancy-associated plasma protein A (PAPP-A) during the first trimester had a moderate to high predictive accuracy for stillbirth related to placental abruption, small-for-gestational-age or pre-eclampsia (positive and negative LRs from 6.3 to 14.1, and from 0.1 to 0.4, respectively). All biophysical and biochemical tests assessed had a low predictive accuracy for stillbirth as a sole category. CONCLUSIONS Currently, there is no clinically useful first-trimester or second-trimester test to predict stillbirth as a sole category. Uterine artery pulsatility index and maternal serum PAPP-A levels appeared to be good predictors of stillbirth related to placental dysfunction disorders.
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Affiliation(s)
- A Conde-Agudelo
- Perinatology Research Branch, 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, USA
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Chaiworapongsa T, Chaemsaithong P, Korzeniewski SJ, Yeo L, Romero R. Pre-eclampsia part 2: prediction, prevention and management. Nat Rev Nephrol 2014; 10:531-40. [PMID: 25003612 PMCID: PMC5898797 DOI: 10.1038/nrneph.2014.103] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
An antiangiogenic state might constitute a terminal pathway for the multiple aetiologies of pre-eclampsia, especially those resulting from placental abnormalities. The levels of angiogenic and antiangiogenic proteins in maternal blood change prior to a diagnosis of pre-eclampsia, correlate with disease severity and have prognostic value in identifying women who will develop maternal and/or perinatal complications. Potential interventions exist to ameliorate the imbalance of angiogenesis and, hence, might provide opportunities to improve maternal and/or perinatal outcomes in pre-eclampsia. Current strategies for managing pre-eclampsia consist of controlling hypertension, preventing seizures and timely delivery of the fetus. Prediction of pre-eclampsia in the first trimester is of great interest, as early administration of aspirin might reduce the risk of pre-eclampsia, albeit modestly. Combinations of biomarkers typically predict pre-eclampsia better than single biomarkers; however, the encouraging initial results of biomarker studies require external validation in other populations before they can be used to facilitate intervention in patients identified as at increased risk. Angiogenic and antiangiogenic factors might also be useful in triage of symptomatic patients with suspected pre-eclampsia, differentiating pre-eclampsia from exacerbations of pre-existing medical conditions and performing risk assessment in asymptomatic women. This Review article discusses the performance of predictive and prognostic biomarkers for pre-eclampsia, current strategies for preventing and managing the condition and its long-term consequences.
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Affiliation(s)
- 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, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - 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, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - Steven J Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - 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, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
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Navaratnam K, Alfirevic Z, Baker PN, Gluud C, Grüttner B, Kublickiene K, Zeeman G, Kenny LC. A multi-centre phase IIa clinical study of predictive testing for preeclampsia: improved pregnancy outcomes via early detection (IMPROvED). BMC Pregnancy Childbirth 2013; 13:226. [PMID: 24314209 PMCID: PMC4029471 DOI: 10.1186/1471-2393-13-226] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 12/03/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND 5% of first time pregnancies are complicated by pre-eclampsia, the leading cause of maternal death in Europe. No clinically useful screening test exists; consequentially clinicians are unable to offer targeted surveillance or preventative strategies. IMPROvED Consortium members have pioneered a personalised medicine approach to identifying blood-borne biomarkers through recent technological advancements, involving mapping of the blood metabolome and proteome. The key objective is to develop a sensitive, specific, high-throughput and economically viable early pregnancy screening test for pre-eclampsia. METHODS/DESIGN We report the design of a multicentre, phase IIa clinical study aiming to recruit 5000 low risk primiparous women to assess and refine innovative prototype tests based on emerging metabolomic and proteomic technologies. Participation involves maternal phlebotomy at 15 and 20 weeks' gestation, with optional testing and biobanking at 11 and 34 weeks. Blood samples will be analysed using two innovative, proprietary prototype platforms; one metabolomic based and one proteomic based, both of which outperform current biomarker based screening tests at comparable gestations. Analytical and clinical data will be collated and analysed via the Copenhagen Trials Unit. DISCUSSION The IMPROvED study is expected to refine proteomic and metabolomic panels, combined with clinical parameters, and evaluate clinical applicability as an early pregnancy predictive test for pre-eclampsia. If 'at risk' patients can be identified, this will allow stratified care with personalised fetal and maternal surveillance, early diagnosis, timely intervention, and significant health economic savings. The IMPROvED biobank will be accessible to the European scientific community for high quality research into the cause and prevention of adverse pregnancy outcome. TRIAL REGISTRATION Trial registration number NCT01891240The IMPROvED project is funded by the seventh framework programme for Research and Technological development of the EU. http://www.fp7-improved.eu/
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Affiliation(s)
- Kate Navaratnam
- Centre for Womens Health Research, University of Liverpool, First Floor, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK
| | - Zarko Alfirevic
- Centre for Womens Health Research, University of Liverpool, First Floor, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK
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Chaiworapongsa T, Romero R, Korzeniewski SJ, Kusanovic JP, Soto E, Lam J, Dong Z, Than NG, Yeo L, Hernandez-Andrade E, Conde-Agudelo A, Hassan SS. Maternal plasma concentrations of angiogenic/antiangiogenic factors in the third trimester of pregnancy to identify the patient at risk for stillbirth at or near term and severe late preeclampsia. Am J Obstet Gynecol 2013; 208:287.e1-287.e15. [PMID: 23333542 PMCID: PMC4086897 DOI: 10.1016/j.ajog.2013.01.016] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 01/03/2013] [Accepted: 01/09/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine whether maternal plasma concentrations of placental growth factor (PlGF), soluble endoglin (sEng), and soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) at 30-34 weeks of gestation can identify patients at risk for stillbirth, late preeclampsia, and delivery of small-for-gestational-age (SGA) neonates. STUDY DESIGN A prospective cohort study included 1269 singleton pregnant women from whom blood samples were obtained at 30-34 weeks of gestation and who delivered at >34 weeks of gestation. Plasma concentrations of PlGF, sEng, and sVEGFR-1 were determined by enzyme-linked immunosorbent assay. RESULTS The prevalence of late (>34 weeks of gestation) preeclampsia, severe late preeclampsia, stillbirth, and SGA was 3.2% (n = 40), 1.8% (n = 23), 0.4% (n = 5), and 8.5% (n = 108), respectively. A plasma concentration of PlGF/sEng <0.3 MoM was associated with severe late preeclampsia (adjusted odds ratio, 16); the addition of PlGF/sEng to clinical risk factors increased the area under the receiver-operating characteristic curve from 0.76 to 0.88 (P = .03). The ratio of PlGF/sEng or PlGF/sVEGFR-1 in the third trimester outperformed those obtained in the first or second trimester and uterine artery Doppler velocimetry at 20-25 weeks of gestation for the prediction of severe late preeclampsia (comparison of areas under the receiver-operating characteristic curve; each P ≤ .02). Both PlGF/sEng and PlGF/sVEGFR-1 ratios achieved a sensitivity of 74% with a fixed false-positive rate of 15% for the identification of severe late preeclampsia. A plasma concentration of PlGF/sVEGFR-1 <0.12 MoM at 30-34 weeks of gestation had a sensitivity of 80%, a specificity of 94%, and a likelihood ratio of a positive test of 14 for the identification of subsequent stillbirth. Similar findings (sensitivity 80%; specificity 93%) were observed in a separate case-control study. CONCLUSION Risk assessment for stillbirth and severe late preeclampsia in the third trimester is possible with the determination of maternal plasma concentrations of angiogenic and antiangiogenic factors at 30-34 weeks of gestation.
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Affiliation(s)
- Tinnakorn Chaiworapongsa
- Perinatology Research Branch, National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, USA.
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Myers JE, Kenny LC, McCowan LME, Chan EHY, Dekker GA, Poston L, Simpson NAB, North RA. Angiogenic factors combined with clinical risk factors to predict preterm pre-eclampsia in nulliparous women: a predictive test accuracy study. BJOG 2013; 120:1215-23. [PMID: 23906160 DOI: 10.1111/1471-0528.12195] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess the performance of clinical risk factors, uterine artery Doppler and angiogenic markers to predict preterm pre-eclampsia in nulliparous women. DESIGN Predictive test accuracy study. SETTING Prospective multicentre cohort study Screening for Pregnancy Endpoints (SCOPE). METHODS Low-risk nulliparous women with a singleton pregnancy were recruited. Clinical risk factor data were obtained and plasma placental growth factor (PlGF), soluble endoglin and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured at 14-16 weeks of gestation. Prediction models were developed using multivariable stepwise logistic regression. MAIN OUTCOME MEASURE Preterm pre-eclampsia (delivered before 37(+0) weeks of gestation). RESULTS Of the 3529 women recruited, 187 (5.3%) developed pre-eclampsia of whom 47 (1.3%) delivered preterm. Controls (n = 188) were randomly selected from women without preterm pre-eclampsia and included women who developed other pregnancy complications. An area under a receiver operating characteristic curve (AUC) of 0.76 (95% CI 0.67-0.84) was observed using previously reported clinical risk variables. The AUC improved following the addition of PlGF measured at 14-16 weeks (0.84; 95% CI 0.77-0.91), but no further improvement was observed with the addition of uterine artery Doppler or the other angiogenic markers. A sensitivity of 45% (95% CI 0.31-0.59) (5% false-positive rate) and post-test probability of 11% (95% CI 9-13) were observed using clinical risk variables and PlGF measurement. CONCLUSIONS Addition of plasma PlGF at 14-16 weeks of gestation to clinical risk assessment improved the identification of nulliparous women at increased risk of developing preterm pre-eclampsia, but the performance is not sufficient to warrant introduction as a clinical screening test. These findings are marker dependent, not assay dependent; additional markers are needed to achieve clinical utility.
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Affiliation(s)
- J E Myers
- Faculty of Medical and Human Sciences, Maternal & Fetal Heath Research Centre, Institute of Human Development, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, UK.
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