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Allotey J, Snell KI, Smuk M, Hooper R, Chan CL, Ahmed A, Chappell LC, von Dadelszen P, Dodds J, Green M, Kenny L, Khalil A, Khan KS, Mol BW, Myers J, Poston L, Thilaganathan B, Staff AC, Smith GC, Ganzevoort W, Laivuori H, Odibo AO, Ramírez JA, Kingdom J, Daskalakis G, Farrar D, Baschat AA, Seed PT, Prefumo F, da Silva Costa F, Groen H, Audibert F, Masse J, Skråstad RB, Salvesen KÅ, Haavaldsen C, Nagata C, Rumbold AR, Heinonen S, Askie LM, Smits LJ, Vinter CA, Magnus PM, Eero K, Villa PM, Jenum AK, Andersen LB, Norman JE, Ohkuchi A, Eskild A, Bhattacharya S, McAuliffe FM, Galindo A, Herraiz I, Carbillon L, Klipstein-Grobusch K, Yeo S, Teede HJ, Browne JL, Moons KG, Riley RD, Thangaratinam S. Validation and development of models using clinical, biochemical and ultrasound markers for predicting pre-eclampsia: an individual participant data meta-analysis. Health Technol Assess 2021; 24:1-252. [PMID: 33336645 DOI: 10.3310/hta24720] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk is needed to plan management. OBJECTIVES To assess the performance of existing pre-eclampsia prediction models and to develop and validate models for pre-eclampsia using individual participant data meta-analysis. We also estimated the prognostic value of individual markers. DESIGN This was an individual participant data meta-analysis of cohort studies. SETTING Source data from secondary and tertiary care. PREDICTORS We identified predictors from systematic reviews, and prioritised for importance in an international survey. PRIMARY OUTCOMES Early-onset (delivery at < 34 weeks' gestation), late-onset (delivery at ≥ 34 weeks' gestation) and any-onset pre-eclampsia. ANALYSIS We externally validated existing prediction models in UK cohorts and reported their performance in terms of discrimination and calibration. We developed and validated 12 new models based on clinical characteristics, clinical characteristics and biochemical markers, and clinical characteristics and ultrasound markers in the first and second trimesters. We summarised the data set-specific performance of each model using a random-effects meta-analysis. Discrimination was considered promising for C-statistics of ≥ 0.7, and calibration was considered good if the slope was near 1 and calibration-in-the-large was near 0. Heterogeneity was quantified using I 2 and τ2. A decision curve analysis was undertaken to determine the clinical utility (net benefit) of the models. We reported the unadjusted prognostic value of individual predictors for pre-eclampsia as odds ratios with 95% confidence and prediction intervals. RESULTS The International Prediction of Pregnancy Complications network comprised 78 studies (3,570,993 singleton pregnancies) identified from systematic reviews of tests to predict pre-eclampsia. Twenty-four of the 131 published prediction models could be validated in 11 UK cohorts. Summary C-statistics were between 0.6 and 0.7 for most models, and calibration was generally poor owing to large between-study heterogeneity, suggesting model overfitting. The clinical utility of the models varied between showing net harm to showing minimal or no net benefit. The average discrimination for IPPIC models ranged between 0.68 and 0.83. This was highest for the second-trimester clinical characteristics and biochemical markers model to predict early-onset pre-eclampsia, and lowest for the first-trimester clinical characteristics models to predict any pre-eclampsia. Calibration performance was heterogeneous across studies. Net benefit was observed for International Prediction of Pregnancy Complications first and second-trimester clinical characteristics and clinical characteristics and biochemical markers models predicting any pre-eclampsia, when validated in singleton nulliparous women managed in the UK NHS. History of hypertension, parity, smoking, mode of conception, placental growth factor and uterine artery pulsatility index had the strongest unadjusted associations with pre-eclampsia. LIMITATIONS Variations in study population characteristics, type of predictors reported, too few events in some validation cohorts and the type of measurements contributed to heterogeneity in performance of the International Prediction of Pregnancy Complications models. Some published models were not validated because model predictors were unavailable in the individual participant data. CONCLUSION For models that could be validated, predictive performance was generally poor across data sets. Although the International Prediction of Pregnancy Complications models show good predictive performance on average, and in the singleton nulliparous population, heterogeneity in calibration performance is likely across settings. FUTURE WORK Recalibration of model parameters within populations may improve calibration performance. Additional strong predictors need to be identified to improve model performance and consistency. Validation, including examination of calibration heterogeneity, is required for the models we could not validate. STUDY REGISTRATION This study is registered as PROSPERO CRD42015029349. 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. 24, No. 72. See the NIHR Journals Library website for further project information.
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Snell KIE, Allotey J, Smuk M, Hooper R, Chan C, Ahmed A, Chappell LC, Von Dadelszen P, Green M, Kenny L, Khalil A, Khan KS, Mol BW, Myers J, Poston L, Thilaganathan B, Staff AC, Smith GCS, Ganzevoort W, Laivuori H, Odibo AO, Arenas Ramírez J, Kingdom J, Daskalakis G, Farrar D, Baschat AA, Seed PT, Prefumo F, da Silva Costa F, Groen H, Audibert F, Masse J, Skråstad RB, Salvesen KÅ, Haavaldsen C, Nagata C, Rumbold AR, Heinonen S, Askie LM, Smits LJM, Vinter CA, Magnus P, Eero K, Villa PM, Jenum AK, Andersen LB, Norman JE, Ohkuchi A, Eskild A, Bhattacharya S, McAuliffe FM, Galindo A, Herraiz I, Carbillon L, Klipstein-Grobusch K, Yeo SA, Browne JL, Moons KGM, Riley RD, Thangaratinam S. External validation of prognostic models predicting pre-eclampsia: individual participant data meta-analysis. BMC Med 2020; 18:302. [PMID: 33131506 PMCID: PMC7604970 DOI: 10.1186/s12916-020-01766-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/26/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk during pregnancy is required to plan management. Although there are many published prediction models for pre-eclampsia, few have been validated in external data. Our objective was to externally validate published prediction models for pre-eclampsia using individual participant data (IPD) from UK studies, to evaluate whether any of the models can accurately predict the condition when used within the UK healthcare setting. METHODS IPD from 11 UK cohort studies (217,415 pregnant women) within the International Prediction of Pregnancy Complications (IPPIC) pre-eclampsia network contributed to external validation of published prediction models, identified by systematic review. Cohorts that measured all predictor variables in at least one of the identified models and reported pre-eclampsia as an outcome were included for validation. We reported the model predictive performance as discrimination (C-statistic), calibration (calibration plots, calibration slope, calibration-in-the-large), and net benefit. Performance measures were estimated separately in each available study and then, where possible, combined across studies in a random-effects meta-analysis. RESULTS Of 131 published models, 67 provided the full model equation and 24 could be validated in 11 UK cohorts. Most of the models showed modest discrimination with summary C-statistics between 0.6 and 0.7. The calibration of the predicted compared to observed risk was generally poor for most models with observed calibration slopes less than 1, indicating that predictions were generally too extreme, although confidence intervals were wide. There was large between-study heterogeneity in each model's calibration-in-the-large, suggesting poor calibration of the predicted overall risk across populations. In a subset of models, the net benefit of using the models to inform clinical decisions appeared small and limited to probability thresholds between 5 and 7%. CONCLUSIONS The evaluated models had modest predictive performance, with key limitations such as poor calibration (likely due to overfitting in the original development datasets), substantial heterogeneity, and small net benefit across settings. The evidence to support the use of these prediction models for pre-eclampsia in clinical decision-making is limited. Any models that we could not validate should be examined in terms of their predictive performance, net benefit, and heterogeneity across multiple UK settings before consideration for use in practice. TRIAL REGISTRATION PROSPERO ID: CRD42015029349 .
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Affiliation(s)
- Kym I E Snell
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Keele, UK.
| | - John Allotey
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Melanie Smuk
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Richard Hooper
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Claire Chan
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Asif Ahmed
- MirZyme Therapeutics, Innovation Birmingham Campus, Birmingham, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter Von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Marcus Green
- Action on Pre-eclampsia (APEC) Charity, Worcestershire, UK
| | - Louise Kenny
- Faculty Health & Life Sciences, University of Liverpool, Liverpool, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Khalid S Khan
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Jenny Myers
- Maternal and Fetal Health Research Centre, Manchester Academic Health Science Centre, University of Manchester, Central Manchester NHS Trust, Manchester, UK
| | - Lucilla Poston
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Anne C Staff
- Division of Obstetrics and Gynaecology, Oslo University Hospital, and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, NIHR Biomedical Research Centre, Cambridge University, Cambridge, UK
| | - Wessel Ganzevoort
- Department of Obstetrics, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Hannele Laivuori
- Department of Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Technology, Tampere University Hospital and Tampere University, Tampere, Finland
| | | | - Javier Arenas Ramírez
- Department of Obstetrics and Gynaecology, University Hospital de Cabueñes, Gijón, Spain
| | - John Kingdom
- Maternal-Fetal Medicine Division, Department OBGYN, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - George Daskalakis
- Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Diane Farrar
- Bradford Institute for Health Research, Bradford Teaching Hospitals, Bradford, UK
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Federico Prefumo
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
| | - Fabricio da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Francois Audibert
- Department of Obstetrics and Gynecology, CHU Ste Justine, Université de Montréal, Montreal, Canada
| | - Jacques Masse
- Department of Molecular Biology, Medical Biochemistry and Pathology, Laval University, Quebec City, Canada
| | - Ragnhild B Skråstad
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology - NTNU, Trondheim, Norway
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
| | - Kjell Å Salvesen
- Department of Obstetrics and Gynecology, Trondheim University Hospital, Trondheim, Norway
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Camilla Haavaldsen
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
| | - Chie Nagata
- Department of Education for Clinical Research, National Center for Child Health and Development, Tokyo, Japan
| | - Alice R Rumbold
- South Australian Health and Medical Research Institute and Robinson Research Institute, The University of Adelaide, Adelaide, Australia
| | - Seppo Heinonen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lisa M Askie
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Luc J M Smits
- Care and Public Health Research Institute, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Christina A Vinter
- Department of Gynecology and Obstetrics, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Per Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Kajantie Eero
- National Institute for Health and Welfare, Helsinki, Finland
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pia M Villa
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne K Jenum
- General Practice Research Unit (AFE), Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Louise B Andersen
- Institute for Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - Jane E Norman
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Akihide Ohkuchi
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Shimotsuke-shi, Tochigi, Japan
| | - Anne Eskild
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Sohinee Bhattacharya
- Obstetrics & Gynaecology, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Alberto Galindo
- Fetal Medicine Unit, Maternal and Child Health and Development Network (SAMID), Department of Obstetrics and Gynaecology, Hospital Universitario, Instituto de Investigación Hospital, Universidad Complutense de Madrid, Madrid, Spain
| | - Ignacio Herraiz
- Fetal Medicine Unit, Maternal and Child Health and Development Network (SAMID), Department of Obstetrics and Gynaecology, Hospital Universitario, Instituto de Investigación Hospital, Universidad Complutense de Madrid, Madrid, Spain
| | - Lionel Carbillon
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris Université Paris, Paris, France
| | - Kerstin Klipstein-Grobusch
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Seon Ae Yeo
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joyce L Browne
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karel G M Moons
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Cochrane Netherlands, Utrecht, The Netherlands
| | - Richard D Riley
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, WHO Collaborating Centre for Women's Health, University of Birmingham, Birmingham, UK
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Antwi E, Amoakoh-Coleman M, Vieira DL, Madhavaram S, Koram KA, Grobbee DE, Agyepong IA, Klipstein-Grobusch K. Systematic review of prediction models for gestational hypertension and preeclampsia. PLoS One 2020; 15:e0230955. [PMID: 32315307 PMCID: PMC7173928 DOI: 10.1371/journal.pone.0230955] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 03/12/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Prediction models for gestational hypertension and preeclampsia have been developed with data and assumptions from developed countries. Their suitability and application for low resource settings have not been tested. This review aimed to identify and assess the methodological quality of prediction models for gestational hypertension and pre-eclampsia with reference to their application in low resource settings. METHODS Using combinations of keywords for gestational hypertension, preeclampsia and prediction models seven databases were searched to identify prediction models developed with maternal data obtained before 20 weeks of pregnancy and including at least three predictors (Prospero registration CRD 42017078786). Prediction model characteristics and performance measures were extracted using the CHARMS, STROBE and TRIPOD checklists. The National Institute of Health quality assessment tools for observational cohort and cross-sectional studies were used for study quality appraisal. RESULTS We retrieved 8,309 articles out of which 40 articles were eligible for review. Seventy-seven percent of all the prediction models combined biomarkers with maternal clinical characteristics. Biomarkers used as predictors in most models were pregnancy associated plasma protein-A (PAPP-A) and placental growth factor (PlGF). Only five studies were conducted in a low-and middle income country. CONCLUSIONS Most of the studies evaluated did not completely follow the CHARMS, TRIPOD and STROBE guidelines in prediction model development and reporting. Adherence to these guidelines will improve prediction modelling studies and subsequent application of prediction models in clinical practice. Prediction models using maternal characteristics, with good discrimination and calibration, should be externally validated for use in low and middle income countries where biomarker assays are not routinely available.
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Affiliation(s)
- Edward Antwi
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Ghana Health Service, Accra, Ghana
| | - Mary Amoakoh-Coleman
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Epidemiology Department, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Dorice L. Vieira
- New York University Health Sciences Library, New York University School of Medicine, New York, NY, United States of America
| | - Shreya Madhavaram
- New York University Health Sciences Library, New York University School of Medicine, New York, NY, United States of America
| | - Kwadwo A. Koram
- Epidemiology Department, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Diederick E. Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Mosimann B, Amylidi-Mohr SK, Surbek D, Raio L. FIRST TRIMESTER SCREENING FOR PREECLAMPSIA - A SYSTEMATIC REVIEW. Hypertens Pregnancy 2019; 39:1-11. [PMID: 31670986 DOI: 10.1080/10641955.2019.1682009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective: To increase the detection rate of preterm preeclampsia (PE) first trimester combined screening tests are being developed. The aim of this review is to create an overview of the currently investigated screening markers, algorithms and their validations.Methods: Comprehensive review of the literature concerning first trimester screening for PEResults and conclusions: Studies investigating a total of 160 biochemical, 6 biophysical and 14 ultrasound markers could be identified. Of the 21 algorithms published, mainly the algorithm published by the Fetal Medicine Foundation London has been validated. This algorithm performes significantly better than screening by anamnestic risk factors only.
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Affiliation(s)
- Beatrice Mosimann
- Department of Obstetrics and Gynecology, University Hospital, University of Bern, Bern, Switzerland
| | - Sofia K Amylidi-Mohr
- Department of Obstetrics and Gynecology, University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynecology, University Hospital, University of Bern, Bern, Switzerland
| | - Luigi Raio
- Department of Obstetrics and Gynecology, University Hospital, University of Bern, Bern, Switzerland
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Lamain-de Ruiter M, Kwee A, Naaktgeboren CA, Louhanepessy RD, De Groot I, Evers IM, Groenendaal F, Hering YR, Huisjes AJM, Kirpestein C, Monincx WM, Schielen PCJI, Van 't Zelfde A, Van Oirschot CM, Vankan-Buitelaar SA, Vonk MAAW, Wiegers TA, Zwart JJ, Moons KGM, Franx A, Koster MPH. External validation of prognostic models for preeclampsia in a Dutch multicenter prospective cohort. Hypertens Pregnancy 2019; 38:78-88. [PMID: 30892981 DOI: 10.1080/10641955.2019.1584210] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To perform an external validation of all published prognostic models for first-trimester prediction of the risk of developing preeclampsia (PE). METHODS Women <14 weeks of pregnancy were recruited in the Netherlands. All systematically identified prognostic models for PE that contained predictors commonly available were eligible for external validation. RESULTS 3,736 women were included; 87 (2.3%) developed PE. Calibration was poor due to overestimation. Discrimination of 9 models for LO-PE ranged from 0.58 to 0.71 and of 9 models for all PE from 0.55 to 0.75. CONCLUSION Only a few easily applicable prognostic models for all PE showed discrimination above 0.70, which is considered an acceptable performance.
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Affiliation(s)
- Marije Lamain-de Ruiter
- a Department of Obstetrics, Division Woman and Baby , University Medical Center Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Anneke Kwee
- a Department of Obstetrics, Division Woman and Baby , University Medical Center Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Christiana A Naaktgeboren
- b Julius Center for Health Sciences and Primary Care , University Medical Center Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Rebecca D Louhanepessy
- c Department of Medical Oncology , Netherlands Cancer Institute , Amsterdam , The Netherlands
| | - Inge De Groot
- d Livive, Center for Obstetrics , Tilburg , The Netherlands
| | - Inge M Evers
- e Department of Obstetrics , Meander Medical Center , Amersfoort , The Netherlands
| | - Floris Groenendaal
- f Department of Neonatology, Division Woman and Baby , University Medical Center Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Yolanda R Hering
- g Department of Obstetrics , Zuwe Hofpoort Hospital , Woerden , The Netherlands
| | - Anjoke J M Huisjes
- h Department of Obstetrics , Gelre Hospital , Apeldoorn , The Netherlands
| | - Cornel Kirpestein
- i Department of Obstetrics , Hospital Rivierenland , Tiel , The Netherlands
| | - Wilma M Monincx
- j Department of Obstetrics , St. Antonius Hospital , Nieuwegein , The Netherland
| | - Peter C J I Schielen
- k Center for Infectious Diseases Research, Diagnostics and Screening (IDS) , National Institute for Public Health and the Environment (RIVM) , Bilthoven , The Netherlands
| | | | | | | | | | - Therese A Wiegers
- p Netherlands Institute for health services research (NIVEL) , Utrecht , The Netherlands
| | - Joost J Zwart
- q Department of Obstetrics , Deventer Hospital , Deventer , The Netherlands
| | - Karel G M Moons
- b Julius Center for Health Sciences and Primary Care , University Medical Center Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Arie Franx
- a Department of Obstetrics, Division Woman and Baby , University Medical Center Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Maria P H Koster
- a Department of Obstetrics, Division Woman and Baby , University Medical Center Utrecht, Utrecht University , Utrecht , The Netherlands.,r Department of Obstetrics and Gynecology, Erasmus Medical Center , University Medical Center Rotterdam , Rotterdam , the Netherlands
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Meertens LJE, Scheepers HCJ, van Kuijk SMJ, Aardenburg R, van Dooren IMA, Langenveld J, van Wijck AM, Zwaan I, Spaanderman MEA, Smits LJM. External Validation and Clinical Usefulness of First Trimester Prediction Models for the Risk of Preeclampsia: A Prospective Cohort Study. Fetal Diagn Ther 2018; 45:381-393. [PMID: 30021205 DOI: 10.1159/000490385] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/24/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION This study assessed the external validity of all published first trimester prediction models for the risk of preeclampsia (PE) based on routinely collected maternal predictors. Moreover, the potential utility of the best-performing models in clinical practice was evaluated. MATERIAL AND METHODS Ten prediction models were systematically selected from the literature. We performed a multicenter prospective cohort study in the Netherlands between July 1, 2013, and December 31, 2015. Eligible pregnant women completed a web-based questionnaire before 16 weeks' gestation. The outcome PE was established using postpartum questionnaires and medical records. Predictive performance of each model was assessed by means of discrimination (c-statistic) and a calibration plot. Clinical usefulness was evaluated by means of decision curve analysis and by calculating the potential impact at different risk thresholds. RESULTS The validation cohort contained 2,614 women of whom 76 developed PE (2.9%). Five models showed moderate discriminative performance with c-statistics ranging from 0.73 to 0.77. Adequate calibration was obtained after refitting. The best models were clinically useful over a small range of predicted probabilities. DISCUSSION Five of the ten included first trimester prediction models for PE showed moderate predictive performance. The best models may provide more benefit compared to risk selection as used in current guidelines.
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Affiliation(s)
- Linda J E Meertens
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands,
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynaecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert Aardenburg
- Department of Obstetrics and Gynaecology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Ivo M A van Dooren
- Department of Obstetrics and Gynaecology, Sint Jans Gasthuis Weert, Weert, The Netherlands
| | - Josje Langenveld
- Department of Obstetrics and Gynaecology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Annemieke M van Wijck
- Department of Obstetrics and Gynaecology, VieCuri Medical Center, Venlo, The Netherlands
| | - Iris Zwaan
- Department of Obstetrics and Gynaecology, Laurentius Hospital, Roermond, The Netherlands
| | - Marc E A Spaanderman
- Department of Obstetrics and Gynaecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Luc J M Smits
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Murtoniemi K, Villa PM, Matomäki J, Keikkala E, Vuorela P, Hämäläinen E, Kajantie E, Pesonen AK, Räikkönen K, Taipale P, Stenman UH, Laivuori H. Prediction of pre-eclampsia and its subtypes in high-risk cohort: hyperglycosylated human chorionic gonadotropin in multivariate models. BMC Pregnancy Childbirth 2018; 18:279. [PMID: 29970026 PMCID: PMC6029382 DOI: 10.1186/s12884-018-1908-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/19/2018] [Indexed: 12/16/2022] Open
Abstract
Background The proportion of hyperglycosylated human chorionic gonadotropin (hCG-h) to total human chorionic gonadotropin (%hCG-h) during the first trimester is a promising biomarker for prediction of early-onset pre-eclampsia. We wanted to evaluate the performance of clinical risk factors, mean arterial pressure (MAP), %hCG-h, hCGβ, pregnancy-associated plasma protein A (PAPP-A), placental growth factor (PlGF) and mean pulsatility index of the uterine artery (Uta-PI) in the first trimester in predicting pre-eclampsia (PE) and its subtypes early-onset, late-onset, severe and non-severe PE in a high-risk cohort. Methods We studied a subcohort of 257 high-risk women in the prospectively collected Prediction and Prevention of Pre-eclampsia and Intrauterine Growth Restriction (PREDO) cohort. Multivariate logistic regression was used to construct the prediction models. The first model included background variables and MAP. Additionally, biomarkers were included in the second model and mean Uta-PI was included in the third model. All variables that improved the model fit were included at each step. The area under the curve (AUC) was determined for all models. Results We found that lower levels of serum PlGF concentration were associated with early-onset PE, whereas lower %hCG-h was associated with the late-onset PE. Serum PlGF was lower and hCGβ higher in severe PE, while %hCG-h and serum PAPP-A were lower in non-severe PE. By using multivariate regression analyses the best prediction for all PE was achieved with the third model: AUC was 0.66, and sensitivity 36% at 90% specificity. Third model also gave the highest prediction accuracy for late-onset, severe and non-severe PE: AUC 0.66 with 32% sensitivity, AUC 0.65, 24% sensitivity and AUC 0.60, 22% sensitivity at 90% specificity, respectively. The best prediction for early-onset PE was achieved using the second model: AUC 0.68 and 20% sensitivity at 90% specificity. Conclusions Although the multivariate models did not meet the requirements to be clinically useful screening tools, our results indicate that the biomarker profile in women with risk factors for PE is different according to the subtype of PE. The heterogeneous nature of PE results in difficulty to find new, clinically useful biomarkers for prediction of PE in early pregnancy in high-risk cohorts. Trial registration International Standard Randomised Controlled Trial number ISRCTN14030412, Date of registration 6/09/2007, retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s12884-018-1908-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katja Murtoniemi
- University of Helsinki and Turunmaa District Hospital, Gynaecological Outpatient Clinic, Hospital District of Southwest Finland, Kaskenkatu 13, 20700, Turku, Finland.
| | - Pia M Villa
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, P.O. Box 140, FI-00029, Helsinki, Haartmaninkatu 2, Finland
| | - Jaakko Matomäki
- Department of Biostatistics, University of Turku, FI-20014 TURUN YLIOPISTO, Turku, Finland
| | - Elina Keikkala
- Department of Obstetrics and Gynaecology, Oulu University Hospital and University of Oulu, Kajaanintie 50, 90220, Oulu, Finland
| | - Piia Vuorela
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, P.O. Box 140, FI-00029, Helsinki, Haartmaninkatu 2, Finland.,Finnish Medical Society Duodecim / Current Care, PL 713, Kalevankatu 11 A, 00101, HELSINKI, Finland
| | - Esa Hämäläinen
- HUSLAB and Department of Clinical Chemistry, University of Helsinki and Helsinki University Hospital, PO BOX 720, 00029, Helsinki, Finland
| | - Eero Kajantie
- Hospital for Children and Adolescents, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 11, P.O. Box 281, FI-00029, Helsinki, Finland
| | - Anu-Katriina Pesonen
- Department of Psychology and Logopedics, University of Helsinki, Siltavuorenpenger 1-5, P.O. Box 9, FI-00014, Helsinki, Finland
| | - Katri Räikkönen
- Department of Psychology and Logopedics, University of Helsinki, Siltavuorenpenger 1-5, P.O. Box 9, FI-00014, Helsinki, Finland
| | - Pekka Taipale
- Suomen Terveystalo Oy, Asemakatu 22-24, 70100, Kuopio, Finland
| | - Ulf-Håkan Stenman
- HUSLAB and Department of Clinical Chemistry, University of Helsinki and Helsinki University Hospital, PO BOX 720, 00029, Helsinki, Finland
| | - Hannele Laivuori
- Institute for Molecular Medicine and Medical and Clinical Genetics, University of Helsinki, P.O. Box 63, FI-00014, Helsinki, Finland.,University of Helsinki and Helsinki University Hospital, P.O. Box 63, FI-00014, Helsinki, Finland
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8
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Meertens LJE, Scheepers HC, De Vries RG, Dirksen CD, Korstjens I, Mulder AL, Nieuwenhuijze MJ, Nijhuis JG, Spaanderman ME, Smits LJ. External Validation Study of First Trimester Obstetric Prediction Models (Expect Study I): Research Protocol and Population Characteristics. JMIR Res Protoc 2017; 6:e203. [PMID: 29074472 PMCID: PMC5680517 DOI: 10.2196/resprot.7837] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/25/2017] [Accepted: 07/27/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A number of first-trimester prediction models addressing important obstetric outcomes have been published. However, most models have not been externally validated. External validation is essential before implementing a prediction model in clinical practice. OBJECTIVE The objective of this paper is to describe the design of a study to externally validate existing first trimester obstetric prediction models, based upon maternal characteristics and standard measurements (eg, blood pressure), for the risk of pre-eclampsia (PE), gestational diabetes mellitus (GDM), spontaneous preterm birth (PTB), small-for-gestational-age (SGA) infants, and large-for-gestational-age (LGA) infants among Dutch pregnant women (Expect Study I). The results of a pilot study on the feasibility and acceptability of the recruitment process and the comprehensibility of the Pregnancy Questionnaire 1 are also reported. METHODS A multicenter prospective cohort study was performed in The Netherlands between July 1, 2013 and December 31, 2015. First trimester obstetric prediction models were systematically selected from the literature. Predictor variables were measured by the Web-based Pregnancy Questionnaire 1 and pregnancy outcomes were established using the Postpartum Questionnaire 1 and medical records. Information about maternal health-related quality of life, costs, and satisfaction with Dutch obstetric care was collected from a subsample of women. A pilot study was carried out before the official start of inclusion. External validity of the models will be evaluated by assessing discrimination and calibration. RESULTS Based on the pilot study, minor improvements were made to the recruitment process and online Pregnancy Questionnaire 1. The validation cohort consists of 2614 women. Data analysis of the external validation study is in progress. CONCLUSIONS This study will offer insight into the generalizability of existing, non-invasive first trimester prediction models for various obstetric outcomes in a Dutch obstetric population. An impact study for the evaluation of the best obstetric prediction models in the Dutch setting with respect to their effect on clinical outcomes, costs, and quality of life-Expect Study II-is being planned. TRIAL REGISTRATION Netherlands Trial Registry (NTR): NTR4143; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4143 (Archived by WebCite at http://www.webcitation.org/6t8ijtpd9).
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Affiliation(s)
| | - Hubertina Cj Scheepers
- School for Oncology and Developmental Biology (GROW), Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Raymond G De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, MI, United States.,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands.,Research Centre for Midwifery Science, Faculty of Health, Zuyd University, Maastricht, Netherlands
| | - Carmen D Dirksen
- Care and Public Health Research Institute (CAPHRI), Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, Maastricht, Netherlands
| | - Irene Korstjens
- Research Centre for Midwifery Science, Faculty of Health, Zuyd University, Maastricht, Netherlands
| | - Antonius Lm Mulder
- School for Oncology and Developmental Biology (GROW), Department of Pediatrics, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Marianne J Nieuwenhuijze
- Research Centre for Midwifery Science, Faculty of Health, Zuyd University, Maastricht, Netherlands
| | - Jan G Nijhuis
- School for Oncology and Developmental Biology (GROW), Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Marc Ea Spaanderman
- School for Oncology and Developmental Biology (GROW), Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Luc Jm Smits
- Care and Public Health Research Institute (CAPHRI), Department of Epidemiology, Maastricht University, Maastricht, Netherlands
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9
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Kumar M, Sharma K, Singh S, Singh R, Singh A, Bhattacharjee J. Use of first-trimester placenta growth factor concentration to predict hypertensive disorders of pregnancy in a low-risk Asian population. Int J Gynaecol Obstet 2017; 139:301-306. [DOI: 10.1002/ijgo.12301] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/23/2017] [Accepted: 08/15/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Manisha Kumar
- Department of Obstetrics and Gynecology; Lady Hardinge Medical College; New Delhi India
| | - Karuna Sharma
- Department of Biochemistry; Lady Hardinge Medical College; New Delhi India
| | - Shalini Singh
- Division of Reproductive Biology; Maternal and Child Health; Indian Council of Medical Research; New Delhi India
| | - Ritu Singh
- Department of Biochemistry; Lady Hardinge Medical College; New Delhi India
| | - Abha Singh
- Department of Obstetrics and Gynecology; Lady Hardinge Medical College; New Delhi India
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10
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Scazzocchio E, Crovetto F, Triunfo S, Gratacós E, Figueras F. Validation of a first-trimester screening model for pre-eclampsia in an unselected population. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:188-193. [PMID: 27257033 DOI: 10.1002/uog.15982] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 04/26/2016] [Accepted: 05/27/2016] [Indexed: 05/07/2023]
Abstract
OBJECTIVE To validate the performance of a previously constructed first-trimester predictive model for pre-eclampsia (PE) in routine care of an unselected population. METHODS A validation cohort of 4621 consecutive women attending their routine first-trimester ultrasound examination was used to test a prediction model for PE that had been developed previously in 5170 women. The prediction model included maternal factors, uterine artery Doppler, blood pressure and pregnancy-associated plasma protein-A. Model performance was evaluated using receiver-operating characteristics (ROC) curve analysis and ROC curves from both cohorts were compared unpaired. RESULTS Among the 4203 women included in the final analysis, 169 (4.0%) developed PE, including 141 (3.4%) cases of late-onset PE and 28 (0.7%) cases of early-onset PE. For early-onset PE, the model showed an area under the ROC curve of 0.94 (95% CI, 0.88-0.99), which did not differ significantly (P = 0.37) from that obtained in the construction cohort (0.88 (95% CI, 0.78-0.99)). For late-onset PE, the final model showed an area under the ROC curve of 0.72 (95% CI, 0.66-0.77), which did not differ significantly (P = 0.49) from that obtained in the construction cohort (0.75 (95% CI, 0.67-0.82)). CONCLUSION The prediction model for PE achieved a similar performance to that obtained in the construction cohort when tested on a subsequent cohort of women, confirming its validity as a predictive model for PE. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Scazzocchio
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Obstetrics, Gynecology and Reproductive Medicine Department, Quirón Dexeus Universitari Hospital, Barcelona, Spain
| | - F Crovetto
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - S Triunfo
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - E Gratacós
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - F Figueras
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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11
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Al-Rubaie ZTA, Askie LM, Ray JG, Hudson HM, Lord SJ. The performance of risk prediction models for pre-eclampsia using routinely collected maternal characteristics and comparison with models that include specialised tests and with clinical guideline decision rules: a systematic review. BJOG 2016; 123:1441-52. [DOI: 10.1111/1471-0528.14029] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2016] [Indexed: 12/17/2022]
Affiliation(s)
- ZTA Al-Rubaie
- School of Medicine; The University of Notre Dame Australia; Sydney NSW Australia
| | - LM Askie
- NHMRC Clinical Trials Centre; University of Sydney; Sydney NSW Australia
| | - JG Ray
- Departments of Medicine, Health Policy Management and Evaluation, and Obstetrics and Gynecology; St. Michael's Hospital; University of Toronto; Toronto ON Canada
| | - HM Hudson
- NHMRC Clinical Trials Centre; University of Sydney; Sydney NSW Australia
- Department of Statistics; Macquarie University; Sydney NSW Australia
| | - SJ Lord
- School of Medicine; The University of Notre Dame Australia; Sydney NSW Australia
- NHMRC Clinical Trials Centre; University of Sydney; Sydney NSW Australia
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12
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Pagani G, Reggia R, Andreoli L, Prefumo F, Zatti S, Lojacono A, Tincani A, Frusca T. The role of second trimester uterine artery Doppler in pregnancies with systemic lupus erythematosus. Prenat Diagn 2016; 35:447-52. [PMID: 25346020 DOI: 10.1002/pd.4517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 09/04/2014] [Accepted: 10/17/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this article is to assess the predictive value of second trimester mean uterine artery Doppler pulsatility index (mUtA PI) for pregnancy complications in women with systemic lupus erythematosus (SLE). METHODS Cohort study of consecutive pregnancies complicated with SLE during a period of 12 years is used. SLE diagnosis was made before pregnancy. mUtA PI was measured between 23 + 0 and 26 + 6 weeks' gestation. Pregnancy and neonatal outcomes were collected. Small for gestational age (SGA) was defined as birth weight <10th percentile. Adverse pregnancy outcome (APO) was defined as one of the following: pre-eclampsia (PE), SGA, placental abruption, stillbirth, or neonatal death. Differential diagnosis between PE and renal flare was made according to SLE-disease activity index. RESULTS There are 70 pregnancies in 64 women. PE was observed in four cases (6%), SGA in five cases (7%), and APO in seven cases (10%). mUtA PI showed a sensitivity and a specificity of 1.0 (95% CI 0.5-1.0) and 1.0 (95% CI 0.95-1.0) for PE, 0.40 (95% CI 0.12-0.77) and 0.97 (95% CI 0.89-0.99) for SGA, and 0.57 (95% CI 0.25-0.84) and 1.0 (95% CI 0.94-1.0) for APO, respectively. CONCLUSION Our findings suggest that uterine artery Doppler is confirmed to be a high sensitivity and a high specificity test for predicting PE even in SLE patients.
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Affiliation(s)
- Giorgio Pagani
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Spedali Civili and University of Brescia, Brescia, Italy
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13
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Stott D, Bolten M, Salman M, Paraschiv D, Clark K, Kametas NA. Maternal demographics and hemodynamics for the prediction of fetal growth restriction at booking, in pregnancies at high risk for placental insufficiency. Acta Obstet Gynecol Scand 2016; 95:329-38. [DOI: 10.1111/aogs.12823] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 11/03/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel Stott
- Division of Women's Health; King's College Hospital; Antenatal Hypertension Clinic; London UK
| | - Mareike Bolten
- Division of Women's Health; King's College Hospital; Antenatal Hypertension Clinic; London UK
| | - Mona Salman
- Division of Women's Health; King's College Hospital; Antenatal Hypertension Clinic; London UK
| | - Daniela Paraschiv
- Division of Women's Health; King's College Hospital; Antenatal Hypertension Clinic; London UK
| | - Katherine Clark
- Division of Women's Health; King's College Hospital; Antenatal Hypertension Clinic; London UK
| | - Nikos A. Kametas
- Division of Women's Health; King's College Hospital; Antenatal Hypertension Clinic; London UK
- Division of Women's Health; King's College Hospital; Harris Birthright Research Centre for Fetal Medicine; London UK
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14
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Kleinrouweler CE, Cheong-See FM, Collins GS, Kwee A, Thangaratinam S, Khan KS, Mol BWJ, Pajkrt E, Moons KG, Schuit E. Prognostic models in obstetrics: available, but far from applicable. Am J Obstet Gynecol 2016; 214:79-90.e36. [PMID: 26070707 DOI: 10.1016/j.ajog.2015.06.013] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 05/20/2015] [Accepted: 06/01/2015] [Indexed: 12/18/2022]
Abstract
Health care provision is increasingly focused on the prediction of patients' individual risk for developing a particular health outcome in planning further tests and treatments. There has been a steady increase in the development and publication of prognostic models for various maternal and fetal outcomes in obstetrics. We undertook a systematic review to give an overview of the current status of available prognostic models in obstetrics in the context of their potential advantages and the process of developing and validating models. Important aspects to consider when assessing a prognostic model are discussed and recommendations on how to proceed on this within the obstetric domain are given. We searched MEDLINE (up to July 2012) for articles developing prognostic models in obstetrics. We identified 177 papers that reported the development of 263 prognostic models for 40 different outcomes. The most frequently predicted outcomes were preeclampsia (n = 69), preterm delivery (n = 63), mode of delivery (n = 22), gestational hypertension (n = 11), and small-for-gestational-age infants (n = 10). The performance of newer models was generally not better than that of older models predicting the same outcome. The most important measures of predictive accuracy (ie, a model's discrimination and calibration) were often (82.9%, 218/263) not both assessed. Very few developed models were validated in data other than the development data (8.7%, 23/263). Only two-thirds of the papers (62.4%, 164/263) presented the model such that validation in other populations was possible, and the clinical applicability was discussed in only 11.0% (29/263). The impact of developed models on clinical practice was unknown. We identified a large number of prognostic models in obstetrics, but there is relatively little evidence about their performance, impact, and usefulness in clinical practice so that at this point, clinical implementation cannot be recommended. New efforts should be directed toward evaluating the performance and impact of the existing models.
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15
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Scala C, Bhide A, Familiari A, Pagani G, Khalil A, Papageorghiou A, Thilaganathan B. Number of episodes of reduced fetal movement at term: association with adverse perinatal outcome. Am J Obstet Gynecol 2015. [PMID: 26205461 DOI: 10.1016/j.ajog.2015.07.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aims of this study were evaluation of the association of reduced fetal movements (RFM) and small-for-gestational-age (SGA) birth at term and to explore if fetal and maternal outcomes are different with single vs repeated episodes of RFM and normal fetal assessment test results. STUDY DESIGN This was a retrospective cohort study of all singleton pregnancies referred for RFMs at a tertiary fetal medicine unit from January 2008 through September 2014. Ultrasound and Doppler indices were obtained from a computerized ultrasound database and pregnancy outcome was collected from hospital records. RESULTS Of the 21,944 women with a singleton pregnancy booked for maternity care during the study period, 1234 women (5.62%) reported RFMs >36+0 weeks. Of these, 1029 women (83.4%) reported a single episode of RFM and 205 (16.6%) had ≥2 presentations for RFM. Women with repeated RFMs had a significantly higher mean uterine artery pulsatility index in the second trimester. The prevalence of SGA baby at birth in women presenting with a single episode as compared to repeated episodes of RFM was 9.8% and 44.2%, respectively (odds ratio, 7.3; 95% confidence interval, 5.1-10.4; P < .05). CONCLUSION Repeated episodes of RFMs at term are more likely to occur in women with high second-trimester uterine artery Doppler resistance indices and are strongly associated with the birth of SGA infants. Women presenting with repeated episodes of RFM should be treated as being at high risk of placental dysfunction irrespective of the results of prenatal ultrasound and Doppler assessment.
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Affiliation(s)
- Carolina Scala
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom.
| | - Amar Bhide
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom
| | - Alessandra Familiari
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom
| | - Giorgio Pagani
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom
| | - Aris Papageorghiou
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom
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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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Baschat AA. First-trimester screening for pre-eclampsia: moving from personalized risk prediction to prevention. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:119-129. [PMID: 25627093 DOI: 10.1002/uog.14770] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- A A Baschat
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, The Johns Hopkins Hospital, 600 North Wolfe Street, Nelson 228, Baltimore, Maryland, 21287, USA.
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Tuuli M, Cahill A, Macones G, Odibo A, Goetzinger K. Development and validation of a risk factor scoring system for first-trimester prediction of preeclampsia. Am J Perinatol 2014; 31:1049-56. [PMID: 24705967 PMCID: PMC4185255 DOI: 10.1055/s-0034-1371705] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of this study was to develop a multiparameter risk-based scoring system for first-trimester prediction of preeclampsia and to validate this scoring system in our patient population. STUDY DESIGN Secondary analysis of a prospective cohort of 1,200 patients presenting for first-trimester aneuploidy screening. Maternal serum pregnancy-associated plasma protein A (PAPP-A) levels were measured and bilateral uterine artery (UA) Doppler studies performed. Using the first half of the study population, a prediction model for preeclampsia was created. Test performance characteristics were used to determine the optimal score for predicting preeclampsia. This model was then validated in the second half of the population. RESULTS Significant risk factors and their weighted scores derived from the prediction model were chronic hypertension (4), history of preeclampsia (3), pregestational diabetes (2), body mass index ≥ 30 kg/m(2) (2), bilateral UA notching (1), and PAPP-A MoM < 10 th percentile (1). The area under the curve (AUC) for the risk scoring system was 0.76 (95% confidence interval [CI], 0.69-0.83), and the optimal threshold for predicting preeclampsia was a total score of ≥ 6. This AUC did not differ significantly from the AUC observed in our validation cohort (AUC, 0.78 [95% CI, 0.69-0.86]; p = 0.75]. CONCLUSION Our proposed risk factor scoring system demonstrates modest accuracy but excellent reproducibility for first-trimester prediction of preeclampsia.
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Affiliation(s)
- Methodius Tuuli
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - Alison Cahill
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - George Macones
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - Anthony Odibo
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - Katherine Goetzinger
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
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19
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Baschat AA, Magder LS, Doyle LE, Atlas RO, Jenkins CB, Blitzer MG. Prediction of preeclampsia utilizing the first trimester screening examination. Am J Obstet Gynecol 2014; 211:514.e1-7. [PMID: 24746997 DOI: 10.1016/j.ajog.2014.04.018] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/27/2014] [Accepted: 04/12/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To derive a prediction rule for preeclampsia and early onset preeclampsia requiring delivery <34 weeks using first trimester maternal, ultrasound, and serum markers. STUDY DESIGN Prospective cohort study of women enrolled at first trimester screening. Maternal history, demographics, anthropometry, ultrasound parameters, and serum analytes were compared between women with preeclampsia and normal outcome. The prediction rule was derived by Lasso logistic regression analysis. RESULTS In 2441 women, 108 (4.4%) women developed preeclampsia, and 18 (0.7%) early preeclampsia. Nulliparity, prior hypertension, diabetes, prior preeclampsia, mean arterial pressure, and the log pregnancy-associate pregnancy protein-A multiples of the median were primary risk factors. Prediction rules for preeclampsia/early preeclampsia had an area under the curve of 0.82/0.83 respectively. Preeclampsia was predicted with 49% sensitivity and early preeclampsia with 55% sensitivity for a 10% false positive rate. CONCLUSION First trimester prediction rules using parameters currently available at first trimester screening identify a significant proportion of women with subsequent preeclampsia.
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Affiliation(s)
- Ahmet A Baschat
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Lauren E Doyle
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Robert O Atlas
- Department of Obstetrics and Gynecology, Mercy Medical Center, Baltimore, MD
| | - Chuka B Jenkins
- Department of Obstetrics and Gynecology, MedStar Harbor Hospital, Baltimore, MD
| | - Miriam G Blitzer
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
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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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Oliveira N, Magder LS, Blitzer MG, Baschat AA. First-trimester prediction of pre-eclampsia: external validity of algorithms in a prospectively enrolled cohort. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:279-85. [PMID: 24913190 DOI: 10.1002/uog.13435] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/22/2014] [Accepted: 05/23/2014] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To evaluate the performance of published first-trimester prediction algorithms for pre-eclampsia (PE) in a prospectively enrolled cohort of women. METHOD A MEDLINE search identified first-trimester screening-prediction algorithms for early-onset (requiring delivery < 34 weeks) and late-onset (requiring delivery ≥ 34 weeks) PE. Maternal variables, ultrasound parameters and biomarkers were determined prospectively in singleton pregnancies enrolled between 9 and 14 weeks. Prediction algorithms were applied to this population to calculate predicted probabilities for PE. The performance of the prediction algorithms was compared with that in the original publication and evaluated for factors explaining differences in prediction. RESULTS Six early and two late PE prediction algorithms were applicable to 871-2962 women, depending on the variables required. The prevalence of early PE was 1.0-1.2% and of late PE was 4.1-5.0% in these patient subsets. One early PE prediction algorithm performed better than in the original publication (80% detection rate (DR) of early PE for 10% false-positive rate (FPR)); the remaining five prediction algorithms underperformed (29-53% DR). Prediction algorithms for late PE also underperformed (18-31% DR, 10% FPR). Applying the screening cut-offs based on the highest Youden index probability scores correctly detected 40-80% of women developing early PE and 71-82% who developed late PE. Exclusion of patients on first-trimester aspirin resulted in DRs of 40-83% and 65-82% for early and late PE, respectively. CONCLUSION First-trimester prediction algorithms for PE share a high negative predictive value if applied to an external population but underperform in their ability to correctly identify women who develop PE. Further research is required to determine the factors responsible for the suboptimal external validity.
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Affiliation(s)
- N Oliveira
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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22
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Oliveira N, Doyle LE, Atlas RO, Jenkins CB, Blitzer MG, Baschat AA. External validity of first-trimester algorithms in the prediction of pre-eclampsia disease severity. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:286-292. [PMID: 24912952 DOI: 10.1002/uog.13433] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 05/22/2014] [Accepted: 05/30/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To compare disease features in women with pre-eclampsia between those who are correctly identified (true positive) and those who are missed (false negative) when applying first-trimester prediction algorithms for pre-eclampsia to a prospectively enrolled population. METHOD Six first-trimester early (requiring delivery < 34 weeks' gestation) pre-eclampsia algorithms were applied to a prospective cohort of singleton pregnancies enrolled at first-trimester screening. Maternal outcomes, neonatal outcomes and severity parameters for pre-eclampsia were compared between true-positive and false-negative predictions. RESULTS Twenty of 2446 (0.8%) women developed early pre-eclampsia, with 65% of these developing severe features and 20% HELLP syndrome. At enrollment, true-positive cases were more likely to be African-American and chronically hypertensive, while false-negative cases were more likely to be Caucasian. At delivery, true-positive cases were more likely to have pre-eclampsia superimposed on hypertension, severely elevated blood pressure and creatinine level > 1.1 mg/dL. False-negative cases were more likely to have HELLP syndrome (all P < 0.05). CONCLUSION In an urban population with a high prevalence of chronic hypertension, patients who are correctly identified by first-trimester screening models are more likely to develop pre-eclampsia superimposed on chronic hypertension with severely elevated blood pressure and evidence of renal failure. In contrast, patients who are missed by these algorithms are more likely to have HELLP syndrome. Further research is needed to confirm these findings and the algorithm adjustments that may be necessary to better predict pre-eclampsia phenotypes.
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Affiliation(s)
- N Oliveira
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Pagani G, D'Antonio F, Khalil A, Papageorghiou A, Bhide A, Thilaganathan B. Association between reduced fetal movements at term and first trimester markers of impaired placental development. Placenta 2014; 35:606-10. [PMID: 24951173 DOI: 10.1016/j.placenta.2014.04.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 04/11/2014] [Accepted: 04/29/2014] [Indexed: 11/25/2022]
Affiliation(s)
- G Pagani
- Fetal Medicine Unit, Division of Developmental Sciences, St George's Medical School, London, UK
| | - F D'Antonio
- Fetal Medicine Unit, Division of Developmental Sciences, St George's Medical School, London, UK
| | - A Khalil
- Fetal Medicine Unit, Division of Developmental Sciences, St George's Medical School, London, UK
| | - A Papageorghiou
- Fetal Medicine Unit, Division of Developmental Sciences, St George's Medical School, London, UK
| | - A Bhide
- Fetal Medicine Unit, Division of Developmental Sciences, St George's Medical School, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, Division of Developmental Sciences, St George's Medical School, London, UK.
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Crovetto F, Figueras F, Triunfo S, Crispi F, Rodriguez-Sureda V, Peguero A, Dominguez C, Gratacos E. Added value of angiogenic factors for the prediction of early and late preeclampsia in the first trimester of pregnancy. Fetal Diagn Ther 2014; 35:258-66. [PMID: 24714555 DOI: 10.1159/000358302] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 12/26/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To explore the predictive role of angiogenic factors for the prediction of early and late preeclampsia (PE) in the first trimester. METHODS A nested case-control study, within a cohort of 5,759 pregnancies, including 28 cases of early, 84 of late PE (cut-off 34 weeks) and 84 controls. Maternal characteristics, mean blood pressure (MAP), uterine artery (UtA) Doppler (11-13 weeks), vascular endothelial growth factor, placental growth factor (PlGF), soluble Fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (8-11 weeks) were measured/recorded. All parameters were normalized by logarithmic transformation; logistic regression analysis was used to predict PE. RESULTS For early PE, significant contributions were chronic hypertension, previous PE, MAP, UtA Doppler, PlGF and sFlt-1. A model including these predictors achieved detection rates (DR) of 77.8 and 88.9% for 5 and 10% false-positive rates (FPR), respectively (AUC 0.958; 95% CI 0.920-0.996). For late PE, significant contributions were provided by body mass index, previous PE, UtA Doppler, PlGF and sFlt-1. The model including these factors achieved DR of 51.2 and 69% at 5 and 10% FPR, respectively (AUC 0.888; 95% CI 0.840-0.936). CONCLUSIONS Among angiogenic factors, not only PlGF but also sFlt-1 substantially improve the prediction for early and late PE. The data need confirmation in larger studies.
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Affiliation(s)
- Francesca Crovetto
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Velikova M, van Scheltinga JT, Lucas PJ, Spaanderman M. Exploiting causal functional relationships in Bayesian network modelling for personalised healthcare. Int J Approx Reason 2014. [DOI: 10.1016/j.ijar.2013.03.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Herraiz I, Escribano D, Gómez-Arriaga PI, Herníndez-García JM, Herraiz MA, Galindo A. Predictive value of sequential models of uterine artery Doppler in pregnancies at high risk for pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:68-74. [PMID: 22102516 DOI: 10.1002/uog.10147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To evaluate the performance of models described previously for the prediction of pre-eclampsia (PE), based on the sequential evaluation of uterine artery resistance at 11-13 weeks and 19-22 weeks, in a high-risk population. METHODS This was a prospective study in 135 women with singleton pregnancies and at least one of the following high-risk conditions: PE and/or intrauterine growth restriction in a previous pregnancy, chronic hypertension, pregestational diabetes, renal disease, body mass index > 30 kg/m(2) , autoimmune disease (systemic lupus erythematosus, antiphospholipid syndrome or rheumatoid arthritis) and thrombophilia. Mean uterine artery pulsatility index (mUtA-PI) at 11-13 and at 19-22 weeks' gestation was measured and analyzed according to quantitative and semi-quantitative models, to predict late PE (resulting in delivery ≥ 34 weeks) and early PE (delivery < 34 weeks). RESULTS Late PE developed in 21 (15.6%) pregnancies and early PE in six (4.4%). Using mUtA-PI, the detection rates of late and early PE for a false-positive rate of 10% were 14.3% and 33.3%, respectively, at 11-13 weeks, and 19.0% and 66.7%, respectively, at 19-22 weeks. Using a semi-quantitative approach, the group of pregnant women with mUtA-PI ≥ 90(th) percentile at both 11-13 and 19-22 weeks had a greater risk for early PE (odds ratio, 21.4 (95% CI, 2.5-184.7)) compared with the group with mUtA-PI < 90(th) percentile at both periods. Using a quantitative approach, there was relative worsening in the mUtA-PI (multiples of the median) from the first to the second trimester in all cases of early PE. CONCLUSION The application of semi-quantitative and especially quantitative models to evaluate sequential changes in uterine artery Doppler findings between the first and second trimesters could be of additional value in assessing high-risk women regarding their true risk of developing early PE.
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Affiliation(s)
- I Herraiz
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
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Pedrosa AC, Matias A. Screening for pre-eclampsia: a systematic review of tests combining uterine artery Doppler with other markers. J Perinat Med 2011; 39:619-35. [PMID: 21848482 DOI: 10.1515/jpm.2011.077] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS To perform a systematic review of screening for pre-eclampsia (PE) with the combination of uterine artery Doppler (UAD), maternal history, mean arterial pressure and/or maternal serum markers. METHODS We identified eligible studies through a search of Medline, and, for each included study, we assessed the risk of bias and extracted relevant data. We reported the performance of screening tests according to the target population (low- or high-risk), the trimester of screening (first and/or second) and the subset of PE screened for (early and late). RESULTS Several tests provided moderate or convincing prediction of early PE, but screening for late PE was poor. Although UAD is more accurate in the second trimester, we found encouraging results for first-trimester screening when it was combined with other markers. Performance of screening was consistently lower in populations with risk factors for PE in the maternal history. CONCLUSIONS We present encouraging results for the prediction of early PE, even in the first trimester of pregnancy. The different performance of tests in screening for early vs. late PE, and of low- vs. high-risk populations, supports the concept that PE is a heterogeneous disease.
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Affiliation(s)
- Ana Catarina Pedrosa
- Department of Obstetrics and Gynecology, Faculty of Medicine of the University of Porto, Portugal.
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28
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Prospective evaluation of ultrasound and biochemical-based multivariable models for the prediction of late pre-eclampsia. Prenat Diagn 2011; 31:1147-52. [DOI: 10.1002/pd.2849] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Revised: 07/19/2011] [Accepted: 08/02/2011] [Indexed: 11/07/2022]
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Cuckle HS. Screening for pre-eclampsia--lessons from aneuploidy screening. Placenta 2011; 32 Suppl:S42-8. [PMID: 21257082 DOI: 10.1016/j.placenta.2010.07.015] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 07/26/2010] [Accepted: 07/28/2010] [Indexed: 01/14/2023]
Abstract
BACKGROUND Antenatal screening for aneuploidy is an established routine clinical practice worldwide. The same statistical methodology, developed and refined over three decades, might be adapted to screening for pre-eclampsia. METHODS The published literature is reviewed for evidence that the methodology is valid for pre-eclampsia using first trimester maternal serum PP13, PAPP-A, PlGF, ADAM12 and inhibin A, together with MAP and uterine artery Doppler PI. Risk is estimated for both early onset pre-eclampsia, requiring delivery before 34 weeks, or late onset disease. Prior risk from the background prevalence multiplied by likelihood ratios (LRs) for ethnicity, parity, adiposity and family history is multiplied by an LR from the screening marker profile. Markers are expressed in multiples of the gestation-specific median and adjusted for body mass, ethnicity and smoking status as appropriate. A standardized population with a fixed distribution of risk factors and a multi-variate Gaussian model of marker profiles is used to predict performance. RESULTS There is sufficient published data to estimate individual risks reasonably well. Modeling predicts that using PAPP-A and one other serum marker, together with the physical markers more than two-thirds of early and one-third of late onset cases can be detected by classifying less than 2% of pregnancies as high risk; three-quarters of early case could be detected with a 5% high risk rate. CONCLUSION Whilst more data on some markers is still required modeling so far suggests that extending first trimester aneuploidy screening programs to include pre-eclampsia screening would yield a high detection. However, prospective studies are needed to verify the model predictions.
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Affiliation(s)
- H S Cuckle
- Department of Obsterics and Gynecology, Columbia University Medical Center, 622 W. 168th Street, PH1666, New York, NY 10032, USA.
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North RA, McCowan LME, Dekker GA, Poston L, Chan EHY, Stewart AW, Black MA, Taylor RS, Walker JJ, Baker PN, Kenny LC. Clinical risk prediction for pre-eclampsia in nulliparous women: development of model in international prospective cohort. BMJ 2011; 342:d1875. [PMID: 21474517 PMCID: PMC3072235 DOI: 10.1136/bmj.d1875] [Citation(s) in RCA: 291] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To develop a predictive model for pre-eclampsia based on clinical risk factors for nulliparous women and to identify a subgroup at increased risk, in whom specialist referral might be indicated. DESIGN Prospective multicentre cohort. SETTING Five centres in Auckland, New Zealand; Adelaide, Australia; Manchester and London, United Kingdom; and Cork, Republic of Ireland. PARTICIPANTS 3572 "healthy" nulliparous women with a singleton pregnancy from a large international study; data on pregnancy outcome were available for 3529 (99%). MAIN OUTCOME MEASURE Pre-eclampsia defined as ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg, or both, on at least two occasions four hours apart after 20 weeks' gestation but before the onset of labour, or postpartum, with either proteinuria or any multisystem complication. Preterm pre-eclampsia was defined as women with pre-eclampsia delivered before 37(+0) weeks' gestation. In the stepwise logistic regression the comparison group was women without pre-eclampsia. RESULTS Of the 3529 women, 186 (5.3%) developed pre-eclampsia, including 47 (1.3%) with preterm pre-eclampsia. Clinical risk factors at 14-16 weeks' gestation were age, mean arterial blood pressure, body mass index (BMI), family history of pre-eclampsia, family history of coronary heart disease, maternal birth weight, and vaginal bleeding for at least five days. Factors associated with reduced risk were a previous single miscarriage with the same partner, taking at least 12 months to conceive, high intake of fruit, cigarette smoking, and alcohol use in the first trimester. The area under the receiver operating characteristics curve (AUC), under internal validation, was 0.71. Addition of uterine artery Doppler indices did not improve performance (internal validation AUC 0.71). A framework for specialist referral was developed based on a probability of pre-eclampsia generated by the model of at least 15% or an abnormal uterine artery Doppler waveform in a subset of women with single risk factors. Nine per cent of nulliparous women would be referred for a specialist opinion, of whom 21% would develop pre-eclampsia. The relative risk for developing pre-eclampsia and preterm pre-eclampsia in women referred to a specialist compared with standard care was 5.5 and 12.2, respectively. CONCLUSIONS The ability to predict pre-eclampsia in healthy nulliparous women using clinical phenotype is modest and requires external validation in other populations. If validated, it could provide a personalised clinical risk profile for nulliparous women to which biomarkers could be added. Trial registration ACTRN12607000551493.
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Affiliation(s)
- Robyn A North
- Division of Women's Health, King's College London, London, United Kingdom.
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Herraiz García I, López Jiménez AE, Gómez Arriaga PI, Escribano Abad D, Galindo Izquierdo A. Doppler de arterias uterinas y marcadores angiogénicos (sFlt-1/PlGF): futuras implicaciones para la predicción y el diagnóstico de la preeclampsia. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.diapre.2010.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Current world literature. Curr Opin Obstet Gynecol 2011; 23:135-41. [PMID: 21386682 DOI: 10.1097/gco.0b013e32834506b7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Sonography is a fundamental tool in the management of pregnancies affected by maternal diabetes. Purposeful use of ultrasound in each trimester provides an invaluable amount of information about the developing fetus including gestational age and growth patterns, anatomical structure and function, assessment of fetal well-being, and prediction of adverse outcome. There are great ongoing research efforts in this field of prenatal diagnosis and management, yet even more are needed.
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Affiliation(s)
- Jennifer M McNamara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, 4911 Barnes-Jewish Plaza, 5th Floor Maternity Building, Campus Box 8064, Saint Louis, MO 63110, USA.
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Van Kuijk SMJ, Sep SJS, Nelemans PJ, Smits LJM. How long do preconception risk prediction models hold? Influence of selective fertility on model performance. Paediatr Perinat Epidemiol 2010; 24:602-7. [PMID: 20955238 DOI: 10.1111/j.1365-3016.2010.01153.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Risk estimates derived from preconception prediction models can be used to counsel women with regard to any future pregnancies. Women with a high predicted risk of an adverse pregnancy outcome may decide more frequently not to try for another pregnancy than women with a low predicted risk. This prediction-guided selective fertility can cause a change in the composition of the pregnant population with respect to those parameters that are included in the prediction model. The question is whether such a change in composition could influence the performance parameters of the prediction model, such as sensitivity, specificity, positive and negative predictive values as well as the discriminative ability, when evaluating risks in the new population and whether it could compromise the longevity of the model. Using a hypothetical example, we show that the original sensitivity and specificity estimates of a preconception prediction model for an adverse pregnancy outcome no longer hold when the model is applied to a population affected by model-based selective fertility: sensitivity decreases, while specificity increases. However, individual patient risk estimates remain unbiased and discriminative ability, expressed as the area under the receiver operating characteristic curve, remains unaffected.
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Affiliation(s)
- Sander M J Van Kuijk
- Department of Epidemiology, Maastricht University Medical Centre, Maastricht, The Netherlands.
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