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Rolnik DL, Syngelaki A, O'Gorman N, Wright D, Nicolaides KH, Poon LC. Aspirin for evidence-based preeclampsia prevention trial: effects of aspirin on maternal serum pregnancy-associated plasma protein A and placental growth factor trajectories in pregnancy. Am J Obstet Gynecol 2024; 231:342.e1-342.e9. [PMID: 38151219 DOI: 10.1016/j.ajog.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/14/2023] [Accepted: 12/20/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND The exact mechanism by which aspirin prevents preeclampsia remains unclear. Its effects on serum placental biomarkers throughout pregnancy are also unknown. OBJECTIVE To investigate the effects of aspirin on serum pregnancy-associated plasma protein A and placental growth factor trajectories using repeated measures from women at increased risk of preterm preeclampsia. STUDY DESIGN This was a longitudinal secondary analysis of the Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-based Preeclampsia Prevention trial using repeated measures of pregnancy-associated plasma protein A and placental growth factor. In the trial, 1620 women at increased risk of preterm preeclampsia were identified using the Fetal Medicine Foundation algorithm at 11 to 13+6 weeks of gestation, of whom 798 were randomly assigned to receive aspirin 150 mg and 822 to receive placebo daily from before 14 weeks to 36 weeks of gestation. Serum biomarkers were measured at baseline and follow-up visits at 19 to 24, 32 to 34, and 36 weeks of gestation. Generalized additive mixed models with treatment by gestational age interaction terms were used to investigate the effect of aspirin on biomarker trajectories over time. RESULTS Overall, there were 5507 pregnancy-associated plasma protein A and 5523 placental growth factor measurements. Raw pregnancy-associated plasma protein A values increased over time, and raw placental growth factor increased until 32 weeks of gestation followed by a decline. The multiple of the median mean values of the same biomarkers were consistently below 1.0 multiple of the median, reflecting the high-risk profile of the study population. Trajectories of mean pregnancy-associated plasma protein A and placental growth factor multiple of the median values did not differ significantly between the aspirin and placebo groups (aspirin treatment by gestational age interaction P values: .259 and .335, respectively). CONCLUSION In women at increased risk of preterm preeclampsia, aspirin 150 mg daily had no significant effects on pregnancy-associated plasma protein A or placental growth factor trajectories when compared to placebo.
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Affiliation(s)
- Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia.
| | - Argyro Syngelaki
- Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| | - Neil O'Gorman
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - David Wright
- Institute of Health Research, University of Exeter, Exeter, United Kingdom
| | - Kypros H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| | - Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong SAR
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Binder J, Palmrich P, Kalafat E, Haberl C, Schirwani N, Pateisky P, Khalil A. Longitudinal assessment of angiogenic markers in prediction of adverse outcome in women with confirmed pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:843-851. [PMID: 37265117 DOI: 10.1002/uog.26276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Angiogenic marker assessment, such as the ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF), is known to be a useful tool in the prediction of pre-eclampsia (PE). However, evidence from surveillance strategies in pregnancies with a PE diagnosis is lacking. Therefore, we aimed to assess the predictive performance of longitudinal maternal serum angiogenic marker assessment for both maternal and perinatal adverse outcomes when compared to standard laboratory parameters in pregnancies with confirmed PE. METHODS This was a retrospective analysis of prospectively collected data from January 2013 to December 2020 at the Medical University of Vienna. The inclusion criteria were singleton pregnancy with confirmed PE and post-diagnosis maternal serum angiogenic marker assessment at a minimum of two timepoints. The primary outcome was the predictive performance of longitudinal sFlt-1 and PlGF assessment for adverse maternal and perinatal outcomes compared to conventional laboratory monitoring at the same time in pregnancies with confirmed PE. Composite adverse maternal outcome included intensive care unit admission, pulmonary edema, eclampsia and/or death. Composite adverse perinatal outcome included stillbirth, neonatal death, placental abruption, neonatal intensive care unit admission, intraventricular hemorrhage, necrotizing enterocolitis, respiratory distress syndrome and/or mechanical ventilator support. RESULTS In total, 885 post-diagnosis sFlt-1/PlGF ratio measurements were obtained from 323 pregnant women with confirmed PE. For composite adverse maternal outcome, the highest standalone predictive accuracy was obtained using maternal serum sFlt-1/PlGF ratio (area under the receiver-operating-characteristics curve (AUC), 0.72 (95% CI, 0.62-0.81)), creatinine (AUC, 0.71 (95% CI, 0.62-0.81)) and lactate dehydrogenase (LDH) levels (AUC, 0.73 (95% CI, 0.65-0.81)). Maternal platelet levels (AUC, 0.65 (95% CI, 0.55-0.74)), serum alanine aminotransferase (ALT) (AUC, 0.59 (95% CI, 0.49-0.69)) and aspartate aminotransferase (AST) (AUC, 0.61 (95% CI, 0.51-0.71) levels had poor standalone predictive accuracy. The best prediction model consisted of a combination of maternal serum LDH, creatinine levels and sFlt-1/PlGF ratio, which had an AUC of 0.77 (95% CI, 0.68-0.85), significantly higher than sFlt-1/PlGF ratio alone (P = 0.037). For composite adverse perinatal outcome, the highest standalone predictive accuracy was obtained using maternal serum sFlt-1/PlGF ratio (AUC, 0.82 (95% CI, 0.75-0.89)) and creatinine (AUC, 0.74 (95% CI, 0.67-0.80)) levels, sFlt-1/PlGF ratio being superior to creatinine alone (P < 0.001). Maternal serum LDH levels (AUC, 0.65 (95% CI, 0.53-0.74)), platelet count (AUC, 0.57 (95% CI, 0.44-0.67)), ALT (AUC, 0.58 (95% CI, 0.48-0.67)) and AST (AUC, 0.58 (95% CI, 0.48-0.67)) levels had poor standalone predictive accuracy. No combination of biomarkers was superior to maternal serum sFlt-1/PlGF ratio alone for prediction of composite adverse perinatal outcome (P > 0.05 for all). CONCLUSIONS In pregnancies with confirmed PE, longitudinal maternal serum angiogenic marker assessment is a good predictor of adverse maternal and perinatal outcomes and superior to some conventional laboratory parameters. Further studies should focus on optimal surveillance following diagnosis of PE. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Binder
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - P Palmrich
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kalafat
- Department of Obstetrics and Gynecology, School of Medicine, Koc University, Istanbul, Turkey
| | - C Haberl
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - N Schirwani
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - P Pateisky
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Velegrakis A, Kouvidi E, Fragkiadaki P, Sifakis S. Predictive value of the sFlt‑1/PlGF ratio in women with suspected preeclampsia: An update (Review). Int J Mol Med 2023; 52:89. [PMID: 37594116 PMCID: PMC10500221 DOI: 10.3892/ijmm.2023.5292] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/13/2023] [Indexed: 08/19/2023] Open
Abstract
Preeclampsia (PE) is a major complication of pregnancy with an incidence rate of 2‑8% and is a leading cause of maternal mortality and morbidity. The various consequences of severe preeclampsia for the fetus, neonate and child include intrauterine growth retardation (IUGR), fetal hypoxia, oligohydramnios, intrauterine fetal demise, increased perinatal mortality and morbidity, neurodevelopmental disorders and even irreversible brain damage (cerebral palsy). A number of studies have demonstrated that differences in maternal serum concentrations of angiogenic factors between preeclampsia and normotensive pregnancies can be used as biomarkers, either alone or in combination with other markers, to predict the development of PE. The presence in the maternal circulation of two proteins of placental origin, placental growth factor (PlGF) and soluble fms‑like tyrosine kinase 1 (sFlt‑1), has been shown to be of clinical value, as the sFlt‑1/PlGF ratio appears to be the optimal predictive tool for the development of PE. The measurement of their concentration in maternal serum in screening models, serves as predictive marker for the development of PE or IUGR later in gestation. However, further research is required to improve its clinical applicability and provide guidelines for its use worldwide to achieve more consistent clinical management of women with PE.
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Affiliation(s)
- Alexandros Velegrakis
- Department of Obstetrics and Gynecology, University Hospital of Heraklion, 71500 Heraklion, Greece
| | - Elisavet Kouvidi
- Genesis Genoma Lab, Genetic Diagnosis, Clinical Genetics and Research, 15232 Athens, Greece
| | - Persefoni Fragkiadaki
- Laboratory of Toxicology, Medical School, University of Crete, 71003 Heraklion, Greece
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Han L, Holland OJ, Da Silva Costa F, Perkins AV. Potential biomarkers for late-onset and term preeclampsia: A scoping review. Front Physiol 2023; 14:1143543. [PMID: 36969613 PMCID: PMC10036383 DOI: 10.3389/fphys.2023.1143543] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Preeclampsia is a progressive, multisystem pregnancy disorder. According to the time of onset or delivery, preeclampsia has been subclassified into early-onset (<34 weeks) and late-onset (≥34 weeks), or preterm (<37 weeks) and term (≥37 weeks). Preterm preeclampsia can be effectively predicted at 11-13 weeks well before onset, and its incidence can be reduced by preventively using low-dose aspirin. However, late-onset and term preeclampsia are more prevalent than early forms and still lack effective predictive and preventive measures. This scoping review aims to systematically identify the evidence of predictive biomarkers reported in late-onset and term preeclampsia. This study was conducted based on the guidance of the Joanna Briggs Institute (JBI) methodology for scoping reviews. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR) was used to guide the study. The following databases were searched for related studies: PubMed, Web of Science, Scopus, and ProQuest. Search terms contain "preeclampsia," "late-onset," "term," "biomarker," or "marker," and other synonyms combined as appropriate using the Boolean operators "AND" and "OR." The search was restricted to articles published in English from 2012 to August 2022. Publications were selected if study participants were pregnant women and biomarkers were detected in maternal blood or urine samples before late-onset or term preeclampsia diagnosis. The search retrieved 4,257 records, of which 125 studies were included in the final assessment. The results demonstrate that no single molecular biomarker presents sufficient clinical sensitivity and specificity for screening late-onset and term preeclampsia. Multivariable models combining maternal risk factors with biochemical and/or biophysical markers generate higher detection rates, but they need more effective biomarkers and validation data for clinical utility. This review proposes that further research into novel biomarkers for late-onset and term preeclampsia is warranted and important to find strategies to predict this complication. Other critical factors to help identify candidate markers should be considered, such as a consensus on defining preeclampsia subtypes, optimal testing time, and sample types.
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Affiliation(s)
- Luhao Han
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD, Australia
| | - Olivia J. Holland
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD, Australia
| | - Fabricio Da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia
| | - Anthony V. Perkins
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD, Australia
- School of Health, University of the Sunshine Coast, Sunshine Coast, QLD, Australia
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Placental Syndromes-A New Paradigm in Perinatology. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127392. [PMID: 35742640 PMCID: PMC9224387 DOI: 10.3390/ijerph19127392] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 12/10/2022]
Abstract
Placental syndromes include pregnancy loss, fetal growth restriction, preeclampsia, preterm delivery, premature rupture of membranes, placental abruption and intrauterine fetal demise. This paper discusses the common etiopathogenesis of those syndromes and the role of angiogenic biomarkers in their development. Pregnancy implantation, placental development and maternal adaptation are complex processes in which fetal and maternal cells interact. The syncytiotrophoblast, trophoblast, uterine natural killer cells and regulatory T cells interfere and interact in all the above-mentioned processes. The proper angioneogenesis and vasculogenesis of the placenta, as well as maternal circulatory adaptation, are dependent on angiogenic factor expression. Insufficient maternal immunotolerance, dysregulation in uterine natural killer or regulatory T cell function, syncytiotrophoblast and trophoblast ischemia and hypoxia or impaired balance in angiogenic factors are all related to the occurrence of placental syndromes. Differences in the time of impairment onset and its intensity and correlation with other dysfunctions result in the development of a specific syndrome. The clinical manifestations in the form of a combination of specific symptoms determine the diagnosis. However, they are just symptoms of an underlying complex trophoblast disorder.
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Chaiyasit N, Sahota DS, Ma R, Choolani M, Wataganara T, Sim WS, Chaemsaithong P, Wah YMI, Hui SYA, Poon LC. Prospective Evaluation of International Prediction of Pregnancy Complications Collaborative Network Models for Prediction of Preeclampsia: Role of Serum sFlt-1 at 11-13 Weeks' Gestation. Hypertension 2021; 79:314-322. [PMID: 34689595 DOI: 10.1161/hypertensionaha.121.18021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The study aimed to investigate whether serum sFlt-1 (soluble fms-like tyrosine kinase-1) at 11-13 weeks' gestation in pregnancies that subsequently developed preeclampsia was different from those without preeclampsia and compare screening performance of the International Prediction of Pregnancy Complications (IPPIC) reported models, which include various combinations of maternal factors, systolic blood pressure, diastolic blood pressure, PlGF (placental growth factor) and sFlt-1 and the competing risk (CR) models, which include various combinations of maternal factors, mean arterial pressure (MAP) and PlGF for predicting any-onset, early-onset, and late-onset preeclampsia. This was a prospective multicenter study in 7877 singleton pregnancies. The differences of the predictive performance between the IPPIC and CR models were compared. There were 141 women (1.79%) who developed preeclampsia, including 13 cases (0.17%) of early-onset preeclampsia and 128 cases (1.62%) of late-onset preeclampsia. In pregnancies that developed preeclampsia compared to unaffected pregnancies, median serum sFlt-1 levels and its MoMs were not significantly different (p>0.05). There was no significant association between gestational age at delivery and log10 sFlt-1 and log10 sFlt-1 MoM (p>0.05). The areas under the curve of CR models were significantly higher than the IPPIC models for the prediction of any-onset and late-onset preeclampsia but not for early-onset preeclampsia. In conclusion, there are no significant differences in the maternal serum sFlt-1 levels at 11-131 weeks' gestation between women who subsequently develop preeclampsia and those who do not. Moreover, the CR models for the prediction of any-onset and late-onset preeclampsia perform better than the IPPIC reported model.
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Affiliation(s)
- Noppadol Chaiyasit
- From King Chulalongkorn Memorial Hospital, Bangkok, Thailand (Noppadol Chaiyasit)
| | - Daljit S Sahota
- The Chinese University of Hong Kong, Hong Kong SAR (D.S.S., Y.M.I.W., S.Y.A.H., L.C.P.)
| | - Runmei Ma
- First Affiliated Hospital of Kunming Medical University, Kunming, China (R.M.)
| | | | - Tuangsit Wataganara
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (T.W.)
| | - Wen Shan Sim
- KK Women's and Children's Hospital, Singapore (W.S.S.)
| | - Piya Chaemsaithong
- Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (P.C.)
| | - Yi Man Isabella Wah
- The Chinese University of Hong Kong, Hong Kong SAR (D.S.S., Y.M.I.W., S.Y.A.H., L.C.P.)
| | - Shuk Yi Annie Hui
- The Chinese University of Hong Kong, Hong Kong SAR (D.S.S., Y.M.I.W., S.Y.A.H., L.C.P.)
| | - Liona C Poon
- The Chinese University of Hong Kong, Hong Kong SAR (D.S.S., Y.M.I.W., S.Y.A.H., L.C.P.)
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Semmler J, Garcia-Gonzalez C, Sanchez Sierra A, Gallardo Arozena M, Nicolaides KH, Charakida M. Fetal cardiac function at 35-37 weeks' gestation in pregnancies that subsequently develop pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:417-422. [PMID: 33098138 DOI: 10.1002/uog.23521] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To compare fetal cardiac morphology and function between pregnancies that subsequently developed pre-eclampsia (PE) and those that remained normotensive. METHODS This was a prospective observational study in 1574 pregnancies at 35-37 weeks' gestation, including 76 that subsequently developed PE. We carried out comprehensive assessment of fetal cardiac morphology and function including novel imaging modalities, such as speckle-tracking echocardiography, and measured uterine artery pulsatility index, mean arterial pressure (MAP), serum placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1) and cerebroplacental ratio (CPR). The findings in the group that subsequently developed PE were compared to those in pregnancies that remained normotensive. RESULTS In fetuses of mothers who subsequently developed PE, compared to those from normotensive pregnancies, there was a more globular right ventricle, as shown by reduced right ventricular sphericity index, reduced right ventricular systolic contractility, as shown by reduced global longitudinal strain, and reduced left ventricular diastolic function, as shown by increased E/A ratio. On multivariable regression analysis, these indices demonstrated an association with PE, independent of maternal characteristics and fetal size. In pregnancies that subsequently developed PE, compared to those that remained normotensive, MAP, sFlt-1 and the incidence of low birth weight were higher, whereas serum PlGF, CPR and the interval between assessment and delivery were lower. These findings demonstrate that, in pregnancies that develop PE, there is evidence of impaired placentation, reflected in low PlGF and reduced birth weight, placental ischemia, evidenced by increased sFlt-1 which becomes apparent in the interval of 2-4 weeks preceding the clinical onset of PE, and consequent fetal hypoxia-induced redistribution in the fetal circulation, reflected in the low CPR. CONCLUSION Although the etiology of the observed fetal cardiac changes in pregnancies that subsequently develop PE remains unclear, it is possible that the reduction in right-heart systolic function is the consequence of high afterload due to increased placental resistance, whilst the early left ventricular diastolic changes could be due to fetal hypoxia-induced redistribution in the fetal circulation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Semmler
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - C Garcia-Gonzalez
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - A Sanchez Sierra
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - M Gallardo Arozena
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - M Charakida
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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Wertaschnigg D, Rolnik DL, Nie G, Teoh SSY, Syngelaki A, da Silva Costa F, Nicolaides KH. Second- and third-trimester serum levels of growth-differentiation factor-15 in prediction of pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:879-884. [PMID: 32388891 DOI: 10.1002/uog.22070] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 04/25/2020] [Accepted: 11/12/2019] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Pre-eclampsia (PE) is a significant contributor to adverse maternal and perinatal outcome; however, accurate prediction and early diagnosis of this condition remain a challenge. The aim of this study was to compare serum levels of growth-differentiation factor-15 (GDF-15) at three different gestational ages between asymptomatic women who subsequently developed preterm or term PE and healthy controls. METHODS This was a case-control study drawn from a prospective observational study on adverse pregnancy outcomes in women attending for their routine second- and third-trimester hospital visits. Serum GDF-15 was determined in 300 samples using a commercial GDF-15 enzyme-linked immunosorbent assay: 120 samples at 19-24 weeks of gestation, 120 samples at 30-34 weeks and 60 samples at 35-37 weeks. Multiple linear regression was applied to logarithmically transformed GDF-15 control values to evaluate the influence of gestational age at blood sampling and maternal characteristics on GDF-15 results. GDF-15 multiples of the normal median (MoM) values, adjusted for gestational age and maternal characteristics, were compared between pregnancies that subsequently developed preterm or term PE and healthy controls. RESULTS Values of GDF-15 increased with gestational age. There were no significant differences in GDF-15 MoM values between cases of preterm or term PE and normotensive pregnancies at 19-24 or 35-37 weeks of gestation. At 30-34 weeks, GDF-15 MoM values were significantly increased in cases of preterm PE, but not in those who later developed term PE. Elevated GDF-15 MoM values were associated significantly with a shorter interval between sampling at 30-34 weeks and delivery with PE (P = 0.005). CONCLUSION Serum GDF-15 levels at 19-24 or 35-37 weeks of gestation are not predictive of preterm or term PE. At 30-34 weeks, GDF-15 levels are higher in women who subsequently develop preterm PE; however, this difference is small and GDF-15 is unlikely to be useful in clinical practice when used in isolation. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Wertaschnigg
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria
| | - D L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - G Nie
- Centre for Reproductive Health, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
| | - S S Y Teoh
- Centre for Reproductive Health, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - A Syngelaki
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - F da Silva Costa
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
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Serum leukotriene B4 and hydroxyeicosatetraenoic acid in the prediction of pre-eclampsia. Placenta 2020; 103:76-81. [PMID: 33099202 DOI: 10.1016/j.placenta.2020.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/21/2020] [Accepted: 10/09/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Pre-eclampsia (PE) affects 2-8% of pregnancies worldwide. Despite identification of numerous possible biomarkers, accurate prediction and early diagnosis of PE remain challenging. We examined the potential of leukotriene B4 (LTB4) and 15-hydroxyeicosatetraenoic acid (15(S)-HETE) as biomarkers of PE by comparing serum levels at three gestational age (GA) groups between normotensive pregnancies and asymptomatic women who subsequently developed preterm or term-PE. METHODS This is a case-control study drawn from a prospective study of adverse pregnancy outcomes with serum samples collected at 19-24 weeks (n = 48), 30-34 weeks (n = 101) and 35-37 weeks (n = 54) GA. LTB4 and 15(S)-HETE levels were determined by ELISA. Serum level multiples of the median (MoM) were compared between normal and PE-pregnancies. Association between LTB4 and 15(S)-HETE and GA at delivery was investigated with Cox proportional-hazards models. RESULTS Serum LTB4 levels were lower in women of East-Asian ethnicity, higher in women with PE history, and increased with GA in normotensive pregnancies, but not in PE. LTB4 was elevated at 19-24 weeks in women who developed preterm-PE. There was a negative association between LTB4 MoM and interval between sampling and delivery with PE at 19-24 weeks only. Serum 15(S)-HETE levels were not influenced by GA at testing and were elevated in women of South-Asian ethnicity. Median 15(S)-HETE levels were unchanged in preterm and term-PE at any GA. DISCUSSION LTB4 was higher at 19-24 weeks in pregnancies that developed preterm-PE versus unaffected pregnancies, suggesting it is a potentially useful predictive marker of preterm PE in the second trimester.
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Wright D, Wright A, Nicolaides KH. The competing risk approach for prediction of preeclampsia. Am J Obstet Gynecol 2020; 223:12-23.e7. [PMID: 31733203 DOI: 10.1016/j.ajog.2019.11.1247] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/01/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
Abstract
The established method of the assessment of the risk for development of preeclampsia is to identify risk factors from maternal demographic characteristics and medical history; in the presence of such factors, the patient is classified as high risk and in their absence as low risk. Although this approach is simple to perform, it has poor performance of the prediction of preeclampsia and does not provide patient-specific risks. This review describes a new approach that allows the estimation of patient-specific risks of delivery with preeclampsia before any specified gestational age by maternal demographic characteristics and medical history with biomarkers obtained either individually or in combination at any stage in pregnancy. In the competing risks approach, every woman has a personalized distribution of gestational age at delivery with preeclampsia; whether she experiences preeclampsia or not before a specified gestational age depends on competition between delivery before or after the development of preeclampsia. The personalized distribution comes from the application of Bayes theorem to combine a previous distribution, which is determined from maternal factors, with likelihoods from biomarkers. As new data become available, what were posterior probabilities take the role as the previous probability, and data collected at different stages are combined by repeating the application of Bayes theorem to form a new posterior at each stage, which allows for dynamic prediction of preeclampsia. The competing risk model can be used for precision medicine and risk stratification at different stages of pregnancy. In the first trimester, the model has been applied to identify a high-risk group that would benefit from preventative therapeutic interventions. In the second trimester, the model has been used to stratify the population into high-, intermediate-, and low-risk groups in need of different intensities of subsequent monitoring, thereby minimizing unexpected adverse perinatal events. The competing risks model can also be used in surveillance of women presenting to specialist clinics with signs or symptoms of hypertensive disorders; combination of maternal factors and biomarkers provide patient-specific risks for preeclampsia that lead to personalized stratification of the intensity of monitoring, with risks updated on each visit on the basis of biomarker measurements.
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Nicolaides KH, Wright D. Re: Prediction of pre-eclampsia: review of reviews. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:564-565. [PMID: 31584230 DOI: 10.1002/uog.20852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/11/2019] [Indexed: 06/10/2023]
Affiliation(s)
- K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
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Prediction of imminent preeclampsia at 35-37 weeks gestation. Am J Obstet Gynecol 2019; 220:584.e1-584.e11. [PMID: 30738886 DOI: 10.1016/j.ajog.2019.01.235] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 01/22/2019] [Accepted: 01/30/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND In the weeks preceding the clinical onset of preeclampsia, the maternal serum level of the angiogenic placental growth factor is decreased and that of the antiangiogenic factor soluble fms-like tyrosine kinase-1 is increased. Women presenting at specialist clinics with signs or symptoms of hypertensive disorders have been stratified according to concentrations of placental growth factor or the ratio of concentrations of soluble fms-like tyrosine kinase-1 and placental growth factor to determine clinical management for the subsequent 1-4 weeks. An alternative approach for the prediction of preeclampsia is use of the competing risks model, a Bayes' theorem based method, to derive patient-specific risk for preeclampsia by various combinations of maternal characteristics and medical history with multiples of the median values of biomarkers. OBJECTIVE The purpose of this study was to compare the performance of screening for delivery with preeclampsia at ≤2 and ≤4 weeks after assessment at 35+0-36+6 weeks gestation between the use of percentile cut-offs in placental growth factor alone or the soluble fms-like tyrosine kinase-1/placental growth factor ratio and the competing risks model. STUDY DESIGN This was a prospective observational study in women who attended a routine hospital visit at 35+0-36+6 weeks gestation in 2 maternity hospitals in England. The visits included the recording of maternal demographic characteristics and medical history and the measurement of serum placental growth factor and soluble fms-like tyrosine kinase-1 and mean arterial pressure. The areas under the receiver operating characteristics curves were used to compare the predictive performance for preeclampsia with delivery at ≤2 and ≤4 weeks from assessment of screening by placental growth factor alone and the soluble fms-like tyrosine kinase-1/placental growth factor ratio with that of a previously developed competing risks model with a combination of maternal factors, placental growth factor, soluble fms-like tyrosine kinase-1, and mean arterial pressure (triple test). RESULTS First, the study population of 15,247 pregnancies included 326 pregnancies (2.1%) that subsequently experienced preeclampsia. Second, in the screening for delivery with preeclampsia at ≤2 and ≤4 weeks from assessment, the performance of the triple test was superior to that of placental growth factor alone or the soluble fms-like tyrosine kinase-1/placental growth factor ratio. The area under the receiver operating characteristics curves for preeclampsia at ≤2 weeks in screening by the triple test (0.975; 95% confidence interval, 0.964-0.985) was higher than that of placental growth factor alone (0.900; 95% confidence interval, 0.866-0.935; P<.0001) and the soluble fms-like tyrosine kinase-1/placental growth factor ratio (0.932; 95% confidence interval, 0.904-0.960; P=.0001). Similarly, the areas under the receiver operating characteristics curves for preeclampsia at ≤4 weeks in screening by the triple test (0.907; 95% confidence interval, 0.886-0.928) was higher than that of placental growth factor alone (0.827; 95% confidence interval, 0.800-0.854; P<.0001) or the soluble fms-like tyrosine kinase-1/placental growth factor ratio (0.857; 95% confidence interval, 0.830-0.883; P<.0001). Third, at most, screen-positive rates of 2-30% the detection rate of delivery with preeclampsia at ≤2 and ≤4 weeks that was achieved by the triple test was approximately 10% higher than that of the soluble fms-like tyrosine kinase-1/placental growth factor ratio and 20% higher than that of placental growth factor alone; the negative predictive value was similar for the 3 tests. CONCLUSION At 35+0-36+6 weeks gestation, the performance of screening for imminent delivery with preeclampsia by the competing risks model is superior to that of placental growth factor alone or the soluble fms-like tyrosine kinase-1/placental growth factor ratio.
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Sotiriadis A, Hernandez-Andrade E, da Silva Costa F, Ghi T, Glanc P, Khalil A, Martins WP, Odibo AO, Papageorghiou AT, Salomon LJ, Thilaganathan B. ISUOG Practice Guidelines: role of ultrasound in screening for and follow-up of pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:7-22. [PMID: 30320479 DOI: 10.1002/uog.20105] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/15/2018] [Accepted: 07/22/2018] [Indexed: 06/08/2023]
Affiliation(s)
- A Sotiriadis
- Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Hernandez-Andrade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Hutzel Women Hospital, Wayne State University, Detroit, MI, USA
| | - F da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - T Ghi
- Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - P Glanc
- Department of Radiology, University of Toronto, Toronto, Ontario, Canada
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine and Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - A O Odibo
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - A T Papageorghiou
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Nuffield Department of Obstetrics and Gynecology, University of Oxford, Women's Center, John Radcliffe Hospital, Oxford, UK
| | - L J Salomon
- Department of Obstetrics and Fetal Medicine, Hopital Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, Paris Descartes University, Paris, France
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Marshall SA, Cox AG, Parry LJ, Wallace EM. Targeting the vascular dysfunction: Potential treatments for preeclampsia. Microcirculation 2018; 26:e12522. [PMID: 30556222 DOI: 10.1111/micc.12522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/22/2018] [Accepted: 12/10/2018] [Indexed: 12/18/2022]
Abstract
Preeclampsia is a pregnancy-specific disorder, primarily characterized by new-onset hypertension in combination with a variety of other maternal or fetal signs. The pathophysiological mechanisms underlying the disease are still not entirely clear. Systemic maternal vascular dysfunction underlies the clinical features of preeclampsia. It is a result of oxidative stress and the actions of excessive anti-angiogenic factors, such as soluble fms-like tyrosine kinase, soluble endoglin, and activin A, released by a dysfunctional placenta. The vascular dysfunction then leads to impaired regulation and secretion of relaxation factors and an increase in sensitivity/production of constrictors. This results in a more constricted vasculature rather than the relaxed vasodilated state associated with normal pregnancy. Currently, the only effective "treatment" for preeclampsia is delivery of the placenta and therefore the baby. Often, this means a preterm delivery to save the life of the mother, with all the attendant risks and burdens associated with fetal prematurity. To lessen this burden, there is a pressing need for more effective treatments that target the maternal vascular dysfunction that underlies the hypertension. This review details the vascular effects of key drugs undergoing clinical assessment as potential treatments for women with preeclampsia.
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Affiliation(s)
- Sarah A Marshall
- Departments of Obstetrics and Gynaecology and Medicine, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Victoria, Australia
| | - Annie G Cox
- Departments of Obstetrics and Gynaecology and Medicine, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Victoria, Australia
| | - Laura J Parry
- School of BioSciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Euan M Wallace
- Departments of Obstetrics and Gynaecology and Medicine, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Victoria, Australia
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Aghaeepour N, Lehallier B, Baca Q, Ganio EA, Wong RJ, Ghaemi MS, Culos A, El-Sayed YY, Blumenfeld YJ, Druzin ML, Winn VD, Gibbs RS, Tibshirani R, Shaw GM, Stevenson DK, Gaudilliere B, Angst MS. A proteomic clock of human pregnancy. Am J Obstet Gynecol 2018; 218:347.e1-347.e14. [PMID: 29277631 DOI: 10.1016/j.ajog.2017.12.208] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 11/24/2017] [Accepted: 12/18/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Early detection of maladaptive processes underlying pregnancy-related pathologies is desirable because it will enable targeted interventions ahead of clinical manifestations. The quantitative analysis of plasma proteins features prominently among molecular approaches used to detect deviations from normal pregnancy. However, derivation of proteomic signatures sufficiently predictive of pregnancy-related outcomes has been challenging. An important obstacle hindering such efforts were limitations in assay technology, which prevented the broad examination of the plasma proteome. OBJECTIVE The recent availability of a highly multiplexed platform affording the simultaneous measurement of 1310 plasma proteins opens the door for a more explorative approach. The major aim of this study was to examine whether analysis of plasma collected during gestation of term pregnancy would allow identifying a set of proteins that tightly track gestational age. Establishing precisely timed plasma proteomic changes during term pregnancy is a critical step in identifying deviations from regular patterns caused by fetal and maternal maladaptations. A second aim was to gain insight into functional attributes of identified proteins and link such attributes to relevant immunological changes. STUDY DESIGN Pregnant women participated in this longitudinal study. In 2 subsequent sets of 21 (training cohort) and 10 (validation cohort) women, specific blood specimens were collected during the first (7-14 weeks), second (15-20 weeks), and third (24-32 weeks) trimesters and 6 weeks postpartum for analysis with a highly multiplexed aptamer-based platform. An elastic net algorithm was applied to infer a proteomic model predicting gestational age. A bootstrapping procedure and piecewise regression analysis was used to extract the minimum number of proteins required for predicting gestational age without compromising predictive power. Gene ontology analysis was applied to infer enrichment of molecular functions among proteins included in the proteomic model. Changes in abundance of proteins with such functions were linked to immune features predictive of gestational age at the time of sampling in pregnancies delivering at term. RESULTS An independently validated model consisting of 74 proteins strongly predicted gestational age (P = 3.8 × 10-14, R = 0.97). The model could be reduced to 8 proteins without losing its predictive power (P = 1.7 × 10-3, R = 0.91). The 3 top ranked proteins were glypican 3, chorionic somatomammotropin hormone, and granulins. Proteins activating the Janus kinase and signal transducer and activator of transcription pathway were enriched in the proteomic model, chorionic somatomammotropin hormone being the top-ranked protein. Abundance of chorionic somatomammotropin hormone strongly correlated with signal transducer and activator of transcription-5 signaling activity in CD4 T cells, the endogenous cell-signaling event most predictive of gestational age. CONCLUSION Results indicate that precisely timed changes in the plasma proteome during term pregnancy mirror a proteomic clock. Importantly, the combined use of several plasma proteins was required for accurate prediction. The exciting promise of such a clock is that deviations from its regular chronological profile may assist in the early diagnoses of pregnancy-related pathologies, and point to underlying pathophysiology. Functional analysis of the proteomic model generated the novel hypothesis that chrionic somatomammotropin hormone may critically regulate T-cell function during pregnancy.
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Affiliation(s)
- Nima Aghaeepour
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Benoit Lehallier
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, CA
| | - Quentin Baca
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Ed A Ganio
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Ronald J Wong
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Mohammad S Ghaemi
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Anthony Culos
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Yasser Y El-Sayed
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Yair J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Maurice L Druzin
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Virginia D Winn
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Ronald S Gibbs
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Rob Tibshirani
- Department of Biomedical Data Sciences and Statistics, Stanford University School of Medicine, Stanford, CA
| | - Gary M Shaw
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - David K Stevenson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Brice Gaudilliere
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Martin S Angst
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
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Perales A, Delgado JL, de la Calle M, García‐Hernández JA, Escudero AI, Campillos JM, Sarabia MD, Laíz B, Duque M, Navarro M, Calmarza P, Hund M, Álvarez FV. sFlt-1/PlGF for prediction of early-onset pre-eclampsia: STEPS (Study of Early Pre-eclampsia in Spain). ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:373-382. [PMID: 27883242 PMCID: PMC5836987 DOI: 10.1002/uog.17373] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 11/08/2016] [Accepted: 11/11/2016] [Indexed: 05/31/2023]
Abstract
OBJECTIVE A high ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) has been linked to pre-eclampsia (PE). We evaluated the sFlt-1/PlGF ratio as a predictive marker for early-onset PE in women at risk of PE. METHODS This prospective, Spanish, multicenter study included pregnant women with a risk factor for PE, including intrauterine growth restriction, PE, eclampsia or hemolysis, elevated liver enzymes and low platelet count syndrome in previous pregnancy, pregestational diabetes or abnormal uterine artery Doppler. The primary objective was to show that the sFlt-1/PlGF ratio at 20, 24 and 28 weeks' gestation was predictive of early-onset PE (< 34 + 0 weeks). Serum sFlt-1 and PlGF were measured at 20, 24 and 28 weeks. Multivariate logistic regression was used to develop a predictive model. RESULTS A total of 819 women were enrolled, of which 729 were suitable for analysis. Of these, 78 (10.7%) women developed PE (24 early onset and 54 late onset). Median sFlt-1/PlGF ratio at 20, 24 and 28 weeks was 6.3 (interquartile range (IQR), 4.1-9.3), 4.0 (IQR, 2.6-6.3) and 3.3 (IQR, 2.0-5.9), respectively, for women who did not develop PE (controls); 14.5 (IQR, 5.5-43.7), 18.4 (IQR, 8.2-57.9) and 51.9 (IQR, 11.5-145.6) for women with early-onset PE; and 6.7 (IQR, 4.6-9.9), 4.7 (IQR, 2.8-7.2) and 6.0 (IQR, 3.8-10.5) for women with late-onset PE. Compared with early-onset PE, the sFlt-1/PlGF ratio was significantly lower in controls (P < 0.001 at each timepoint) and in women with chronic hypertension (P < 0.001 at each timepoint), gestational hypertension (P < 0.001 at each timepoint) and late-onset PE (P < 0.001 at each timepoint). A prediction model for early-onset PE was developed, which included the sFlt-1/PlGF ratio plus mean arterial pressure, being parous and previous PE, with areas under the receiver-operating characteristics curves of 0.86 (95% CI, 0.77-0.95), 0.91 (95% CI, 0.85-0.97) and 0.93 (95% CI, 0.86-0.99) at 20, 24 and 28 weeks, respectively, and was superior to models using the sFlt-1/PlGF ratio alone or uterine artery mean pulsatility index. CONCLUSIONS The sFlt-1/PlGF ratio can improve prediction of early-onset PE for women at risk of this condition. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A. Perales
- Hospital Universitario y Politécnico La FeValenciaSpain
| | | | | | | | | | | | | | - B. Laíz
- Hospital Universitario y Politécnico La FeValenciaSpain
| | - M. Duque
- Hospital Universitario La PazMadridSpain
| | - M. Navarro
- Hospital Universitario Materno Infantil de CanariasGran CanariaSpain
| | - P. Calmarza
- Hospital Universitario Miguel ServetZaragozaSpain
| | - M. Hund
- Roche Diagnostics International LtdRotkreuzSwitzerland
| | - F. V. Álvarez
- Hospital Universitario Central de AsturiasOviedoSpain
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Andrietti S, Carlucci S, Wright A, Wright D, Nicolaides KH. Repeat measurements of uterine artery pulsatility index, mean arterial pressure and serum placental growth factor at 12, 22 and 32 weeks in prediction of pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:221-227. [PMID: 28078815 DOI: 10.1002/uog.17403] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/08/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To investigate the potential value of repeat measurements of uterine artery pulsatility index (UtA-PI), mean arterial pressure (MAP) and serum placental growth factor (PlGF) at 12, 22 and 32 weeks' gestation in the prediction of pre-eclampsia (PE) developing after 32 weeks. METHODS Data were derived from prospective screening for adverse obstetric outcomes in women attending their routine hospital visit at 11-13, 19-24 and/or 30-34 weeks' gestation in two maternity hospitals in England. UtA-PI, MAP and PlGF were measured. Bayes' theorem was used to combine the a-priori risk from maternal factors with UtA-PI, MAP and PlGF multiples of the median values. The performance of screening for PE developing after the 30-34-week visit by UtA-PI, MAP and PlGF measured at 11-13, 19-24 and 30-34 weeks and their combinations was examined. RESULTS Screening at 30-34 weeks by UtA-PI, MAP and PlGF detected, at a 10% false-positive rate, 79%, 86% and 92% of preterm PE and 42%, 50% and 56% of term PE. The addition of biomarker values at 11-13 and/or 19-24 weeks was not associated with any improvement in the detection rate of preterm PE; in the case of term PE, there was a marginal (< 2%) improvement in detection for UtA-PI and MAP and a modest improvement of about 5% for PlGF. CONCLUSION Measurements of UtA-PI, MAP and PlGF in the first and/or second trimester have a small or no effect on improving the prediction of PE provided by screening in the early third trimester. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S Andrietti
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - S Carlucci
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Tan MY, Wright D, Koutoulas L, Akolekar R, Nicolaides KH. Comparison of screening for pre-eclampsia at 31-34 weeks' gestation by sFlt-1/PlGF ratio and a method combining maternal factors with sFlt-1 and PlGF. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:201-208. [PMID: 27671370 DOI: 10.1002/uog.17307] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/15/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To estimate the patient-specific risk of pre-eclampsia (PE) at 31-34 weeks' gestation by a combination of maternal characteristics and medical history with multiples of the median (MoM) values of serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFlt-1) and to compare the performance of screening to that achieved by the sFlt-1/PlGF ratio. METHODS This was a prospective observational study in women attending a third-trimester ultrasound scan at 31-34 weeks as part of routine pregnancy care. We estimated the performance of screening for PE with delivery within 4 weeks of assessment and PE with delivery from 4 weeks after assessment up to 40 weeks' gestation by the sFlt-1/PlGF ratio and by a method utilizing Bayes' theorem that combines maternal factors and MoM values of sFlt-1 and PlGF. The significance of the difference in screening performance between the two methods was assessed by comparison of the areas under the receiver-operating characteristics curves (AUC). RESULTS The study population of 8063 singleton pregnancies included 231 (2.9%) that subsequently developed PE. In the prediction of delivery with PE at < 4 weeks from assessment, the performance of the method utilizing Bayes' theorem was similar to that using the sFlt-1/PlGF ratio (AUC, 0.987 (95% CI, 0.979-0.995) vs 0.988 (95% CI, 0.981-0.994); P = 0.961). In contrast, the performance of screening for delivery with PE at ≥ 4 weeks after assessment up to 40 weeks' gestation was better with the method utilizing Bayes' theorem than that with the sFlt-1/PlGF ratio (AUC, 0.884 (95% CI, 0.854-0.914) vs 0.818 (95% CI, 0.775-0.860); P < 0.0001). CONCLUSION At 31-34 weeks' gestation the performance of screening for PE delivering at < 4 weeks from assessment by the method utilizing Bayes' theorem is similar to that using the sFlt-1/PlGF ratio, but the former is superior to the latter in prediction of PE delivering ≥ 4 weeks from assessment. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Y Tan
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - L Koutoulas
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - R Akolekar
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
- Department of Fetal Medicine, Medway Maritime Hospital, Gillingham, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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19
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Cuckle H. Rational and irrational ratios. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:275-278. [PMID: 27299851 DOI: 10.1002/uog.15992] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/01/2016] [Accepted: 06/05/2016] [Indexed: 06/06/2023]
Affiliation(s)
- H Cuckle
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA.
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20
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Wright D, Krajewska K, Bogdanova A, Wright A, Nicolaides KH. Maternal serum soluble fms-like tyrosine kinase-1 at 22 and 32 weeks in the prediction of pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:755-761. [PMID: 26726123 DOI: 10.1002/uog.15850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/27/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To investigate the potential value of repeat measurements of maternal serum concentration of soluble fms-like tyrosine kinase-1 (sFlt-1) at 22 and 32 weeks' gestation in the prediction of pre-eclampsia (PE) in women delivering after 32 weeks. METHODS The data were derived from prospective screening for adverse obstetric outcomes in women attending their routine hospital visit at 19-24 and/or 30-34 weeks' gestation in one of two maternity hospitals in England. Serum sFlt-1 was measured in 7565 and 8264 singleton pregnancies at 19-24 and 30-34 weeks, respectively. Bayes' theorem was used to combine the a-priori risk from maternal factors with sFlt-1 multiples of the median (MoM) values. The performance of screening for PE developing after the 30-34-week visit by sFlt-1, measured at 19-24, 30-34 and at both 19-24 and 30-34 weeks was examined. RESULTS In pregnancies with PE, sFlt-1 in both the second and third trimesters was increased and the deviation from normal was inversely related to the gestational age at which delivery became necessary for maternal or fetal indications. Serum sFlt-1 at 19-24 weeks was not useful in predicting PE beyond the 30-34-week visit, but the addition of sFlt-1 at 19-24 weeks improved the prediction of PE provided by sFlt-1 at 30-34 weeks. Screening by maternal factors and sFlt-1 at 30-34 weeks predicted 94% of preterm PE and 54% of term PE, at a false-positive rate of 10%; this was improved to 99% and 64%, respectively, by the additional measurement of sFlt-1 at 19-24 weeks. CONCLUSIONS Measurement of sFlt-1 in the second trimester improves the prediction of PE provided by screening in the early third-trimester. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - K Krajewska
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Bogdanova
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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