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Siepen C, Brennecke S. Does a sFlt-1/PlGF ratio result > 655 before 34 weeks' gestation necessitate preterm delivery within 2 days? A retrospective observational study. J Matern Fetal Neonatal Med 2024; 37:2371047. [PMID: 38926094 DOI: 10.1080/14767058.2024.2371047] [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: 02/08/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Preeclampsia is associated with adverse perinatal outcomes, including fetal growth restriction (FGR) and preterm delivery. The maternal serum ratio of soluble fms-like tyrosine kinase receptor-1 (sFlt-1) to placental growth factor (PlGF) can be used to evaluate placental dysfunction in cases of preeclampsia and FGR. A need for delivery within 2 days has been recommended for sFlt-1/PlGF ratios > 655 (normal ratio < 38) measured before 34 weeks' gestation. However, few studies have assessed this recommendation in a real-world setting and there remains a need for further evidence-based guidance on the use of the ratio in delivery timing planning in this situation. AIM To assess the need for delivery within 2 days associated with sFlt-1/PlGF ratios > 655 before 34 weeks' gestation. METHODS A retrospective audit of all sFlt-1/PlGF ratio test results obtained at a single maternity hospital between September 2016 and November 2022. The primary outcome was time to delivery after recording a ratio > 655 in patients with a pregnancy between 20 + 0 and 33 + 6 weeks' gestation. Statistical analysis was performed using IBM SPSS Statistics v29.0.0.0. RESULTS During the study period a total of 33 patients with suspected or confirmed preeclampsia and/or FGR recorded sFlt-1/PlGF ratios > 655 before 34 + 0 weeks' gestation. Amongst cases with ratios > 655, median time to delivery was 4 days (IQR 1.0-9.0), with 14 (42.4%) delivering in ≤ 2 days, 8 (24.2%) delivering between 2 and 7 days and 11 (33.3%) delivering after 7 days. A significant inverse correlation was observed between time to delivery and gestational age at the time of ratio testing (rs = -0.484, p = 0.004). DISCUSSION This study provides updated recommendations on the use of the sFlt-1/PlGF ratio in predicting the risk of imminent delivery amongst those with high ratios > 655 measured before 34 weeks' gestation. Our results suggest that the risk of imminent delivery can be stratified based on ratio level and gestational age, which in combination with the results of other clinical assessments, can be used to plan delivery timing and allow for considerations of fetal lung maturing corticosteroid and neuroprotective magnesium sulfate therapies prior to delivery.
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Affiliation(s)
- Cassandra Siepen
- Pregnancy Research Centre, Department of Maternal Fetal Medicine, Royal Women's Hospital, Parkville, Australia
- Melbourne Medical School, University of Melbourne, Parkville, Australia
| | - Shaun Brennecke
- Pregnancy Research Centre, Department of Maternal Fetal Medicine, Royal Women's Hospital, Parkville, Australia
- University of Melbourne Department of Obstetrics, Gynaecology and Newborn Health, Royal Women's Hospital, Parkville, Victoria, Australia
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Performance of sFlt-1/PIGF Ratio for the Prediction of Perinatal Outcome in Obese Pre-Eclamptic Women. J Clin Med 2022; 11:jcm11113023. [PMID: 35683415 PMCID: PMC9181651 DOI: 10.3390/jcm11113023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/22/2022] [Accepted: 05/24/2022] [Indexed: 02/04/2023] Open
Abstract
Obese women are at high risk of developing pre-eclampsia (PE). As an altered angiogenic profile is characteristic for PE, measurement of soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PIGF) ratio in the maternal serum can be helpful for PE diagnosis, as well as for adverse perinatal outcome (APO) prediction. There is growing evidence that obesity might influence the level of sFlt-1/PIGF and, therefore, the aim of the study was the evaluation of sFlt-1/PIGF as an APO predictor in obese women with PE. Pre-eclamptic women who had an sFlt-1/PIGF measurement at the time of diagnosis were retrospectively included. Women were classified according to their pre-pregnancy body mass index (BMI) as normal weight (BMI < 25 kg/m2), overweight (BMI > 25−29.9 kg/m2) or obese (BMI ≥ 30 kg/m2). APO was defined as the occurrence of one of the following outcomes: Small for gestational age, defined as a birthweight < 3rd centile, neonatal mortality, neonatal seizures, admission to neonatal unit required (NICU) or respiratory support. A total of 141 women were included. Of them, 28 (20%) patients were obese. ROC (receiver operating characteristic) analysis revealed a high predictive value for sFlt-1/PIGF and APO across the whole study cohort (AUC = 0.880, 95% CI: 0.826−0.936; p < 0.001). However, the subgroup of obese women showed a significantly lower level of sFlt-1 and, therefore, the performance of sFlt-1/PIGF as APO predictor was poorer compared to normal or overweight PE women (AUC = 0.754, 95% CI: 0.552−0.956, p = 0.025). In contrast to normal or overweight women, a ratio of sFlt-1/PIGF < 38 could not rule out APO in women with obesity.
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Iannaccone A, Reisch B, Mavarani L, Darkwah Oppong M, Kimmig R, Mach P, Schmidt B, Köeninger A, Gellhaus A. Soluble endoglin versus sFlt-1/PlGF ratio: detection of preeclampsia, HELLP syndrome, and FGR in a high-risk cohort. Hypertens Pregnancy 2022; 41:159-172. [PMID: 35475405 DOI: 10.1080/10641955.2022.2066119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The angiogenic factors sFlt-1 and PlGF play an established role in the detection of preeclampsia (PE). Recent data suggest that sEng might contribute to the pathogenesis of PE. However, only a few studies so far have addressed its role.This monocentric cross-sectional study of high-risk pregnancies aims to compare the levels of sFlt-1/PlGF ratio and sEng depending on different placental-related adverse pregnancy outcomes. The statistical analysis takes into account Pearson's correlation coefficient between angiogenic factors, the area under the curve estimates (AUCs) for detection, and adjusted odds ratios (aOR) with 95% confidence intervals (95%-CIs). The analysis included 206 patients: 60 controls, 90 PE (59 EOPE, 35 LOPE), 94 FGR, and 35 HELLP cases. Some outcomes overlapped because FGR commonly complicated PE and HELLP syndrome. Serum levels of sFlt-1/PlGF and sEng correlated with each other. Higher levels were observed in HELLP syndrome and EOPE cases. AUCs for sFlt-1/PlGF ratio and sEng were, respectively, 0.915 (95%-Cl 0.87-0.96) and 0.872 (95%-Cl 0.81-0.93) in PE, 0.895 (95%-Cl 0.83-0.96) and 0.878 (95%-Cl 0.81-0.95) in HELLP syndrome, 0.891 (95%-Cl 0.84-0.94), and 0.856 (95%-Cl 0.79-0.92) in FGR.aORsfor sFlt-1/PlGF ratio and sEng were, respectively: 2.69 (95%-Cl 1.86-3.9) and 2.33 (95%-Cl 1.59-3.48) in PE, 2.38 (95%-Cl 1.64-3.44) and 2.28 (95%-Cl 1.55-3.4) in FGR, and 2.10 (95%-Cl 1.45-3.05) and 1.88 (95%-Cl 1.31-2.69) in HELLP syndrome. In addition, the aORs between sFlt-1/PlGF and sEng were very similar but higher for PE and FGR than HELLP syndrome.In conclusion,sEng performed similarly to sFlt-1/PlGF to detect placental dysfunctions.
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Affiliation(s)
- A Iannaccone
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Essen
| | - B Reisch
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Essen
| | - L Mavarani
- Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen DE
| | - M Darkwah Oppong
- Department of Neurosurgery, University of Duisburg-Essen, Essen, Germany
| | - R Kimmig
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Essen
| | - P Mach
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Essen
| | - B Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen DE
| | - A Köeninger
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Essen.,Hedwig Clinic, University of Regensburg, DE
| | - A Gellhaus
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Essen
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Graupner O, Enzensberger C. Prediction of Adverse Pregnancy Outcome Related to Placental Dysfunction Using the sFlt-1/PlGF Ratio: A Narrative Review. Geburtshilfe Frauenheilkd 2021; 81:948-954. [PMID: 34393258 PMCID: PMC8354351 DOI: 10.1055/a-1403-2576] [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] [Received: 12/05/2020] [Accepted: 02/27/2021] [Indexed: 12/18/2022] Open
Abstract
The sFlt-1 (soluble fms-like tyrosine kinase-1)/PlGF (placental growth factor) ratio is a helpful tool for the prediction and diagnosis of preeclampsia (PE). Current data even show that the ratio has the potential to predict adverse pregnancy outcomes (APO) caused by placental pathologies. The aim of this article is to give a brief overview of recent findings on APO predictions based on the sFlt-1/PlGF ratio. The focus is on obstetric pathologies related to placental dysfunction (PD) such as PE and/or fetal growth restriction (FGR). New uses of the sFlt-1/PlGF ratio as a predictor of APO demonstrate its potential with regard to planning hospitalization and corticosteroid administration and the optimal timing of delivery. However, prospective interventional studies are warranted to define the exact role of the sFlt-1/PlGF ratio as a predictor of adverse pregnancy outcomes caused by placental pathologies.
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Affiliation(s)
- Oliver Graupner
- Department of Obstetrics and Gynecology, University Hospital Aachen, RWTH University, Aachen, Germany.,Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University, Munich, Germany
| | - Christian Enzensberger
- Department of Obstetrics and Gynecology, University Hospital Aachen, RWTH University, Aachen, Germany
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Use of the angiogenic biomarker profile to risk stratify patients with fetal growth restriction. Am J Obstet Gynecol MFM 2021; 3:100394. [PMID: 33991706 DOI: 10.1016/j.ajogmf.2021.100394] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/26/2021] [Accepted: 05/03/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Novel angiogenic biomarker profiles have demonstrated emerging evidence for predicting preeclampsia onset, severity, and adverse outcomes. Limited data exist in screening patients with fetal growth restriction for preeclampsia development using angiogenic biomarkers. OBJECTIVE The objective of this study was to risk stratify patients with fetal growth restriction using a soluble fms-like tyrosine kinase-1 to placental growth factor ratio. Previously published cutoff of 38 was used to predict preeclampsia development and severity as well as adverse maternal or neonatal outcomes within a 2-week time period. STUDY DESIGN This was a prospective observational cohort study performed in a single tertiary hospital. Patients with a singleton fetal growth restriction pregnancy between 24 and 37 weeks' gestation were evaluated using serial 2-week encounters from the time of enrollment to delivery. Pregnancies with proven genetic or infectious etiology of fetal growth restriction or congenital anomalies were excluded. Ultrasound growth and Doppler measurements were obtained at the start of every encounter with routine preeclampsia laboratory tests and blood pressure checks when clinically indicated. Maternal serum was collected for all serial encounters and measured for soluble fms-like tyrosine kinase-1 and placental growth factor after delivery in a double-blinded fashion. Maternal charts were reviewed for baseline demographic characteristics, pregnancy diagnoses and outcomes, and neonatal outcomes. RESULTS A total of 45 patients were enrolled for a total of 77 encounters, with the median (quartile 1, quartile 3) gestational age of the study enrolled at 31.43 (28.14-33.57) weeks. Patients were divided into low-risk (ratio of <38) and high-risk (ratio of ≥38) groups. Baseline characteristics of patients did not show any marked differences, including preeclampsia labs or ultrasound parameters, between the 2 groups. Systolic and diastolic blood pressures upon enrollment were statistically elevated when soluble fms-like tyrosine kinase-1 to placental growth factor ratio was ≥38 (P=.02 and P=.01, respectively). Compared to patients with a low ratio, patients with a high ratio had a greater proportion of preeclampsia diagnosis, higher rates of preterm delivery under 34 and 37 weeks gestation, smaller neonatal birthweight, and a shorter time to delivery from testing to delivery. CONCLUSION Among patients with fetal growth restriction, the soluble fms-like tyrosine kinase-1 to placental growth factor ratio may serve as a potential biomarker for identifying at risk patients for developing preeclampsia and subsequently preterm delivery.
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Biomarkers and the Prediction of Adverse Outcomes in Preeclampsia: A Systematic Review and Meta-analysis. Obstet Gynecol 2021; 137:72-81. [PMID: 33278298 DOI: 10.1097/aog.0000000000004149] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To systematically review the performance of soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), and the sFlt-1/PlGF ratio in predicting adverse outcomes in women with preeclampsia. DATA SOURCES We performed a systematic search of MEDLINE, EMBASE, CINAHL, Cochrane, Scopus, ClinicalTrials.gov, and Emcare databases from 1989 to March 2019 to identify studies correlating sFlt-1, PlGF, and the sFlt-1/PlGF ratio with the occurrence of adverse outcomes in women with preeclampsia. METHODS OF STUDY SELECTION Two independent reviewers screened 3,194 studies using Covidence. Studies were included if they examined the performance of sFLT-1, PlGF, or the sFLT-1/PlGF ratio in predicting adverse outcomes in women with suspected or confirmed preeclampsia. TABULATION, INTEGRATION, AND RESULTS We extracted contingency tables with true-positive, false-positive, true-negative, and false-negative results. We calculated sensitivity, specificity, diagnostic odds ratios, and area under the summary receiver operating characteristic curve (area sROC) through a bivariate mixed-effects meta-analysis. Our literature search identified 3,194 articles, of which 33 (n=9,426 patients) were included. There was significant variation in the included studies with regard to the biomarkers and outcomes assessed. As such, few studies (n=4-8) were included in the meta-analysis component with significant heterogeneity between studies (I2=33-99). Nonetheless, both PlGF and the sFlt-1/PlGF ratio demonstrated area sROC values between 0.68 and 0.87 for the prediction of composite adverse maternal and perinatal outcomes, preterm birth and fetal growth restriction. CONCLUSION Placental growth factor and the sFlt-1/PlGF ratio show prognostic promise for adverse outcomes in preeclampsia, but study heterogeneity limits their clinical utility. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019136207.
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OSHOVSKYY V, MYLYTSYA K. Extremely early intrauterine growth restriction with dramatic sFlt-1/PlGF ratio. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2021. [DOI: 10.23736/s0393-3660.20.04323-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Karge A, Seiler A, Flechsenhar S, Haller B, Ortiz JU, Lobmaier SM, Axt-Fliedner R, Enzensberger C, Abel K, Kuschel B, Graupner O. Prediction of adverse perinatal outcome and the mean time until delivery in twin pregnancies with suspected pre-eclampsia using sFlt-1/PIGF ratio. Pregnancy Hypertens 2021; 24:37-43. [PMID: 33647841 DOI: 10.1016/j.preghy.2021.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/02/2020] [Accepted: 02/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE An elevated soluble fms-like tyrosine kinase-1 (sFlt-1) / placental growth factor (PlGF) ratio is associated with adverse perinatal outcome (APO) and the mean time until delivery (MTUD) in singleton pregnancies complicated by pre-eclampsia (PE). Data on APO and MTUD prediction in twin pregnancies using sFlt-1/PlGF ratio are scarce. We evaluated the predictive value of the sFlt-1/PIGF ratio regarding APO and MTUD in twin pregnancies with suspected PE and/or HELLP syndrome. METHODS This is a single center retrospective cohort study. All twin pregnancies with suspected PE/HELLP and determined sFlt-1/PIGF were included. Composite APO (CAPO) was defined as the presence of at least one of the following outcomes: respiratory distress syndrome (RDS), intubation, admission to neonatal intensive care unit (NICU) and arterial umbilical cord pH value < 7.10. Selective fetal growth restriction (s-FGR) was analyzed separately. RESULTS For final analysis, 49 twin pregnancies were included. Median sFlt-1/PIGF ratio was not significantly different in patients with CAPO compared to those without (89.45 vs. 62.00, p = 0.669). MTUD was significantly negative correlated with sFlt-1/PIGF ratio (r = -0.409, p < 0.001). For the whole study cohort, ROC analysis revealed no predictive value for sFlt-1/PIGF and CAPO (AUC = 0.618, 95% CI: 0.387-0.849, p = 0.254). However, sFlt-1/PIGF ratio showed a predictive value for s-FGR (AUC = 0.755, 95% CI: 0.545-0.965, p = 0.032). CONCLUSION In twin pregnancies with PE and/or HELLP, sFlt-1/PIGF ratio may be helpful for s-FGR prediction and decision-making regarding close monitoring of high-risk patients. However, further prospective studies are warranted to define the role of sFlt-1/PlGF ratio as outcome predictor in twin pregnancies.
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Affiliation(s)
- Anne Karge
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Alina Seiler
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sarah Flechsenhar
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- Institute for Medical Informatics, Statistics and Epidemiology (IMedIS), University Hospital rechts der Isar, Technical University of Munich, Germany
| | - Javier U Ortiz
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Silvia M Lobmaier
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Roland Axt-Fliedner
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Christian Enzensberger
- Department of Obstetrics and Gynecology, University Hospital RWTH Aachen, RWTH Aachen University, Aachen, Germany
| | - Kathrin Abel
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bettina Kuschel
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Oliver Graupner
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany; Department of Obstetrics and Gynecology, University Hospital RWTH Aachen, RWTH Aachen University, Aachen, Germany
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Mirkovic L, Tulic I, Stankovic S, Soldatovic I. Prediction of adverse maternal outcomes of early severe preeclampsia. Pregnancy Hypertens 2020; 22:144-150. [PMID: 32979729 DOI: 10.1016/j.preghy.2020.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/04/2020] [Accepted: 09/12/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Assess soluble FMS-like tyrosine kinase-1/placental growth factor ratio (sFlt-1/PlGF) diagnostic accuracy for predicting adverse maternal outcome in patients with early severe preeclampsia, and whether its predictive performance is superior to full preeclampsia integrated estimate of risk score (PIERS). STUDY DESIGN Prospective study enrolled patients with early severe preeclampsia (defined by American College of Obstetricians and Gynaecologists 2013 guidelines) admitted to the Clinic for Obstetrics and Gynaecology, Clinical Center of Serbia intensive care unit. Patients underwent delivery to terminate preeclampsia within 48 h of admission. PIERS was generated and blood samples taken at admission. Multiple pregnancies and gestational ages outside 24-34 weeks were excluded. sFlt-1 and PlGF serum concentrations were measured using Elecsys® assays and cobas e 601 analyser. Maternal complications were recorded for seven days post-delivery. MAIN OUTCOME MEASURES Diagnostic accuracy (sensitivity and specificity), and predictive performance (receiver operating characteristic area under curve [AUC]) vs. PIERS, of sFlt-1/PlGF for predicting adverse maternal outcome. RESULTS Of 89 patients enrolled, 61 were evaluable. Median frequency of adverse maternal outcomes within seven days of delivery was two. Median sFlt-1/PlGF and PIERS were 521·0 and 5·0%, respectively. sFlt-1/PlGF showed greater correlation with complication number than PIERS (Spearman's rho: 0·728 [p < 0·001] and 0·134 [p = 0·304], respectively). AUC for sFlt-1/PlGF and PIERS were 0·853 and 0·628, respectively. A 377·0 sFlt-1/PlGF cut-off was optimal for predicting complications (75·0% sensitivity; 92·3% specificity). CONCLUSIONS sFlt-1/PlGF correlated more closely with number of adverse maternal outcomes than PIERS, and was a superior predictor of maternal complications.
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Affiliation(s)
- Ljiljana Mirkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Obstetrics and Gynecology, Clinical Center of Serbia, Belgrade, Serbia.
| | - Ivan Tulic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia
| | - Ivan Soldatovic
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Villalaín C, Herraiz I, Valle L, Mendoza M, Delgado JL, Vázquez‐Fernández M, Martínez‐Uriarte J, Melchor Í, Caamiña S, Fernández‐Oliva A, Villar OP, Galindo A. Maternal and Perinatal Outcomes Associated With Extremely High Values for the sFlt-1 (Soluble fms-Like Tyrosine Kinase 1)/PlGF (Placental Growth Factor) Ratio. J Am Heart Assoc 2020; 9:e015548. [PMID: 32248765 PMCID: PMC7428600 DOI: 10.1161/jaha.119.015548] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 03/02/2020] [Indexed: 12/19/2022]
Abstract
Background There is little knowledge about the significance of extremely high values (>655) for the ratio of sFlt-1 (soluble fms-like tyrosine kinase 1) to PlGF (placental growth factor). We aim to describe the time-to-delivery interval and maternal and perinatal outcomes when such values are demonstrated while assessing suspected or confirmed placental dysfunction based on clinical or sonographic criteria. Methods and Results A multicenter retrospective cohort study was performed on 237 singleton gestations between 20+0 and 37+0 weeks included at the time of first demonstrating a sFlt-1/PlGF ratio >655. Clinicians were aware of this result, but standard protocols were followed for delivery indication. Main outcomes were compared for women with and without preeclampsia at inclusion. In those with preeclampsia (n=185, of whom 77.3% had fetal growth restriction), severe preeclampsia features and fetal growth restriction in stages III or IV were present in 49.2% and 13.5% cases, respectively, at inclusion and in 77.3% and 28.6% cases, respectively, at delivery. In the group without preeclampsia (n=52, 82.7% had fetal growth restriction), these figures were 0% and 30.8%, respectively, at inclusion and 21.2% and 50%, respectively, at delivery. Interestingly, 28% of women without initial preeclampsia developed it later. The median time to delivery was 4 days (interquartile range: 1-6 days) and 7 days (interquartile range: 3-12 days), respectively (P<0.01). Overall, perinatal mortality was 62.1% before 24 weeks; severe morbidity surpassed 50% before 29 weeks but became absent from 34 weeks. Maternal serious morbidity was high at any gestational age. Conclusions An sFlt-1/PlGF ratio >655 is almost invariably associated with preeclampsia or fetal growth restriction that progresses rapidly. In our tertiary care settings, we observed that maternal adverse outcomes were high throughout gestation, whereas perinatal adverse outcomes diminished as pregnancy advanced.
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Affiliation(s)
- Cecilia Villalaín
- Fetal Medicine Unit‐SAMIDDepartment of Obstetrics and GynaecologyHospital Universitario 12 de OctubreInstituto de Investigación Hospital 12 de Octubre (imas12)Universidad Complutense de MadridMadridSpain
| | - Ignacio Herraiz
- Fetal Medicine Unit‐SAMIDDepartment of Obstetrics and GynaecologyHospital Universitario 12 de OctubreInstituto de Investigación Hospital 12 de Octubre (imas12)Universidad Complutense de MadridMadridSpain
| | - Leonor Valle
- Department of ObstetricsHospital Universitario Materno‐Infantil de Las Palmas de Gran CanariaLas Palmas de Gran CanariaSpain
| | - Manel Mendoza
- Department of ObstetricsMaternal‐Foetal Medicine Unit‐SAMIDVall d’Hebron University HospitalUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Juan Luis Delgado
- Department of Obstetrics and GynecologyHospital Universitario Virgen de la ArrixacaMurciaSpain
| | | | - Juan Martínez‐Uriarte
- Department of Obstetrics and GynecologyHospital General Universitario Santa LucíaCartagenaSpain
| | - Íñigo Melchor
- Obstetrics and Gynecology DepartmentBiocruces Bizkaia Health Research InstituteCruces University Hospital (UPV/EHU)VizcayaSpain
| | - Sara Caamiña
- Department of Obstetrics and GynecologyHospital Universitario Nuestra Señora de la CandelariaSanta Cruz de TenerifeSpain
| | - Antoni Fernández‐Oliva
- Maternal‐Foetal Medicine UnitDepartment of Obstetrics and GynecologyHospital de la Santa Creu i Sant PauBarcelonaSpain
| | - Olga Patricia Villar
- Fetal Medicine Unit‐SAMIDDepartment of Obstetrics and GynaecologyHospital Universitario 12 de OctubreInstituto de Investigación Hospital 12 de Octubre (imas12)Universidad Complutense de MadridMadridSpain
| | - Alberto Galindo
- Fetal Medicine Unit‐SAMIDDepartment of Obstetrics and GynaecologyHospital Universitario 12 de OctubreInstituto de Investigación Hospital 12 de Octubre (imas12)Universidad Complutense de MadridMadridSpain
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Graupner O, Karge A, Flechsenhar S, Seiler A, Haller B, Ortiz JU, Lobmaier SM, Axt-Fliedner R, Enzensberger C, Abel K, Kuschel B. Role of sFlt-1/PlGF ratio and feto-maternal Doppler for the prediction of adverse perinatal outcome in late-onset pre-eclampsia. Arch Gynecol Obstet 2019; 301:375-385. [PMID: 31734756 DOI: 10.1007/s00404-019-05365-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 10/30/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE The sFlt-1 (soluble fms-like tyrosine kinase-1)/PlGF (placental growth factor) ratio and uterine artery Doppler have shown to be helpful in the diagnosis of pre-eclampsia (PE). The predictive value of the cerebroplacental ratio (CPR) regarding adverse perinatal outcome (APO) in low-risk pregnancies is intensively discussed. We evaluated the extent to which sFlt-1/PlGF ratio and feto-maternal Doppler may be useful in predicting APO in singleton pregnancies complicated by late-onset PE and/or HELLP syndrome. METHODS This is a retrospective study from 2010 to 2018 consisting of singleton pregnancies with confirmed diagnosis of late-onset (lo ≥ 34 weeks) PE/HELLP syndrome in which sFlt-1/PlGF ratio and feto-maternal Doppler (mUtA-PI: mean uterine artery pulsatility index and CPR) were determined. The ability of sFlt-1/PlGF ratio, mUtA-PI, CPR and their combination to predict APO or SGA was evaluated using receiver operating characteristic (ROC) curves. RESULTS 67 patients were included in the final analysis. Of these, sFlt-1/PlGF was > 110 (defining angiogenic lo PE) in 40.3% (27/67), mUtA-PI was above the 95th centile in 34.3% (23/67) patients and CPR was lower than the 5th centile in 10.4% (7/67). Abnormal sFlt-1/PlGF and mUtA-PI as well as CPR were associated with a lower birth weight (BW). Late-preterm birth (< 37 weeks) as well as postnatal diagnosis of small for gestational age (SGA: BW < 3rd centile) was significantly more often in angiogenic lo PE cases. Neither sFlt-1/PIGF nor CPR or mUtA-PI were APO predictors. Only for sFlt-1/PlGF, ROC analysis revealed a significant predictive value for postnatal SGA (AUC = 0.856, p = 0.001, 95% CI 0.75-0.97). There was no statistical added value of combined SGA predictors as compared to sFlt-1/PlGF alone. CONCLUSIONS In patients with lo PE, adding sFlt-1/PlGF ratio to routine antepartum fetal surveillance may be useful to identify cases of postnatal SGA. However, further prospective studies are warranted to define the role of feto-maternal Doppler and sFlt-1/PlGF ratio as outcome predictors.
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Affiliation(s)
- Oliver Graupner
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Anne Karge
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Sarah Flechsenhar
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Alina Seiler
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Haller
- Institute for Medical Informatics, Statistics and Epidemiology (IMedIS), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Javier U Ortiz
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Silvia M Lobmaier
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Roland Axt-Fliedner
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Christian Enzensberger
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Kathrin Abel
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bettina Kuschel
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Ngene NC, Moodley J, Naicker T. The performance of pre-delivery serum concentrations of angiogenic factors in predicting postpartum antihypertensive drug therapy following abdominal delivery in severe preeclampsia and normotensive pregnancy. PLoS One 2019; 14:e0215807. [PMID: 31022243 PMCID: PMC6485032 DOI: 10.1371/journal.pone.0215807] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 04/09/2019] [Indexed: 01/07/2023] Open
Abstract
Background The imbalance between circulating concentrations of anti- and pro-angiogenic
factors is usually intense in preeclampsia with severe features (sPE). It is
possible that pre-delivery circulating levels of angiogenic factors in sPE
may be associated with postpartum antihypertensive drug requirements. Objective To determine the predictive association between maternal pre-delivery serum
concentrations of angiogenic factors and the use of ≥3 slow- and/or a
rapid-acting antihypertensive drug therapy in sPE on postpartum days zero to
three following caesarean delivery. Study design Women with sPE (n = 50) and normotensive pregnancies (n = 90) were recruited
prior to childbirth. Serum samples were obtained from each participant <
48 hours before delivery to assess the concentrations of placental growth
factor (PIGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) using the
Roche Elecsys platform. Each participant was followed up on postpartum days
zero, one, two and three to monitor BP and confirm antihypertensive
treatment. The optimal cut-off thresholds of sFlt-1/PIGF ratio from receiver
operating characteristic curve predictive of the antihypertensive therapy
were subjected to diagnostic accuracy assessment. Results The majority 58% (29/50) of sPE had multiple severe features of preeclampsia
in the antenatal period with the commonest presentation being severe
hypertension in 88% (44/50) of this group, followed by features of impending
eclampsia which occurred in 42% (21/50). The median gestational age at
delivery was 38 (Interquartile range, IQR 1) vs 36 (IQR 6)
weeks, p < 0.001 in normotensive and sPE groups
respectively. Notably, the median sFlt-1/PIGF ratio in normotensive and sPE
groups were 7.3 (IQR 17.9) and 179.1 (IQR 271.2) respectively,
p < 0.001. Of the 50 sPE participants, 34% (17/50)
had early-onset preeclampsia. The median (IQR) of sFlt-1/PIGF in the early-
and late-onset preeclampsia groups were 313.52 (502.25), and 166.59(195.37)
respectively, p = 0.006. From postpartum days zero to
three, 48% (24/50) of sPE received ≥ 3 slow- and/or a rapid-acting
antihypertensive drug. However, the daily administration of ≥ 3 slow- and/or
a rapid-acting antihypertensive drug in sPE were pre-delivery 26% (13/50),
postpartum day zero 18% (9/50), postpartum day one 34% (17/50), postpartum
day two 24% (12/50) and postpartum day three 20% (10/50). In sPE, the
pre-delivery sFlt-1/PIGF ratio was predictive of administration of ≥3 slow-
and/or a rapid-acting antihypertensive drug on postpartum days zero, one and
two with the optimal cut-off ratio being ≥315.0, ≥181.5 and ≥ 267.8
respectively (sensitivity 72.7–75.0%, specificity 64.7–78.6%, positive
predictive value 40.0–50.0% and negative predictive value 84.6% - 94.3%).
The predictive performance of sFlt-1/PIG ratio on postpartum day 3 among the
sPE was not statistically significant (area under receiver operating
characteristic curve, 0.6; 95% CI, 0.3–0.8). Conclusion A pre-delivery sFlt-1/PIGF ratio (< 181.5) is a promising predictor for
excluding the need for ≥3 slow- and/or a rapid-acting antihypertensive drug
therapy in the immediate postpartum period in sPE.
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Affiliation(s)
- Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynaecology, University of KwaZulu-Natal,
South Africa
- * E-mail:
| | - Jagidesa Moodley
- Women’s Health and HIV Research Group, Department of Obstetrics and
Gynaecology, University of KwaZulu-Natal, South Africa
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