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Lu H, Yu C, Yu X, Yang D, Yu S, Xia L, Lin Y, Yang B, Wu Y, Li G. Effects of Bony Pelvic and Prostate Dimensions on Surgical Difficulty of Robot-Assisted Radical Prostatectomy: An Original Study and Meta-analysis. Ann Surg Oncol 2024:10.1245/s10434-024-15769-w. [PMID: 39080137 DOI: 10.1245/s10434-024-15769-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/25/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Due to the deep location of the prostate within the pelvic cavity, procedures of robot-assisted radical prostatectomy (RARP) might be challenged by the prostate size and the limited pelvic cavity space. This study aimed to investigate the roles of bony pelvic and prostate dimensions in RARP procedures by an original study coupled with a meta-analysis. METHODS In the original study, patients undergoing multiport RARP between 2021 and 2022 were consecutively assessed. The associations of anatomic features with operative time (OT), estimated blood loss (EBL), and positive surgical margin (PSM) were evaluated using linear and logistic regression analyses as well as restricted cubic spline (RCS) analysis. Based on machine-learning algorithms, this study established predictive models for surgical difficulty and interpreted the model using SHapley Additive exPlanation (SHAP). In the meta-analysis, three databases were searched for eligible studies. Quantitative syntheses were subsequently performed. RESULTS Overall, 219 patients were enrolled in the original study. Prostate volume (PV) and the prostate volume-to-pelvic cavity index (PCI) ratio (PV-to-PCI ratio) were significantly associated with longer OT (P < 0.05). In the RCS models, U-shaped associations were observed between the prostate anteroposterior diameter (PAD) and OT, and between the prostate height (PH) and EBL, and an L-shaped association was observed between the anteroposterior diameter of the pelvic inlet (API) and EBL. The XGBoost model was superior to the logistic regression model in predicting prolonged OT. The meta-analysis demonstrated that greater PV was significantly associated with longer OT (β = 0.20; 95% confidence interval [CI] 0.12-0.27; odds ratio [OR] = 1.05; 95% CI 1.00-1.11), and a smaller PV could increase the risk of PSM (OR = 0.82; 95% CI 0.77-0.88). CONCLUSIONS A large prostate within a narrow and deep pelvis might suggest increased surgical difficulty of RARP. The size of the pelvic inlet also had a great impact on RARP. For PAD and PH, there seemed to be an optimal range with the lowest surgical difficulty. Machine-learning models based on the XGBoost algorithm could be successfully applied to predict the surgical difficulty of RARP.
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Affiliation(s)
- Haohua Lu
- Department of Urology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Chenhao Yu
- Department of Urology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiaojing Yu
- Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Dexin Yang
- Department of Toxicology of School of Public Health, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shicheng Yu
- Department of Urology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Liqun Xia
- Department of Urology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yudong Lin
- Department of Urology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Bowen Yang
- Department of Urology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yihua Wu
- Department of Toxicology of School of Public Health, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Gonghui Li
- Department of Urology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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Thomopoulos C, Hitij JB, De Backer T, Gkaliagkousi E, Kreutz R, Lopez-Sublet M, Marketou M, Mihailidou AS, Olszanecka A, Pechère-Bertschi A, Pérez MP, Persu A, Piani F, Socrates T, Stolarz-Skrzypek K, Cífková R. Management of hypertensive disorders in pregnancy: a Position Statement of the European Society of Hypertension Working Group 'Hypertension in Women'. J Hypertens 2024; 42:1109-1132. [PMID: 38690949 DOI: 10.1097/hjh.0000000000003739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Hypertensive disorders in pregnancy (HDP), remain the leading cause of adverse maternal, fetal, and neonatal outcomes. Epidemiological factors, comorbidities, assisted reproduction techniques, placental disorders, and genetic predisposition determine the burden of the disease. The pathophysiological substrate and the clinical presentation of HDP are multifarious. The latter and the lack of well designed clinical trials in the field explain the absence of consensus on disease management among relevant international societies. Thus, the usual clinical management of HDP is largely empirical. The current position statement of the Working Group 'Hypertension in Women' of the European Society of Hypertension (ESH) aims to employ the current evidence for the management of HDP, discuss the recommendations made in the 2023 ESH guidelines for the management of hypertension, and shed light on controversial issues in the field to stimulate future research.
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Affiliation(s)
- Costas Thomopoulos
- Department of Cardiology, General Hospital of Athens 'Laiko', Athens, Greece
| | - Jana Brguljan Hitij
- Department of Hypertension, University Medical Centre Ljubljana, Medical University Ljubljana, Slovenia
| | - Tine De Backer
- Cardiovascular Center & Clinical Pharmacology, University Hospital Gent, Belgium
| | - Eugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital Faculty of Medicine, Aristotle University of Thessaloniki, Greece
| | - Reinhold Kreutz
- Charite-Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Marilucy Lopez-Sublet
- AP-HP, Hopital Avicenne, Centre d'Excellence Europeen en Hypertension Arterielle, Service de Medecine Interne, INSERM UMR 942 MASCOT, Paris 13-Universite Paris Nord, Bobigny, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists)
| | - Maria Marketou
- School of Medicine, University of Crete, Heraklion, Greece
| | - Anastasia S Mihailidou
- Department of Cardiology and Kolling Institute, Royal North Shore Hospital, St Leonards
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Agnieszka Olszanecka
- 1st Department of Cardiology, Interventional Electrocardiology, and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | | | - Mariana Paula Pérez
- Department of Hypertension. Hospital de Agudos J. M. Ramos Mejía, Buenos Aires, Argentina
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Federica Piani
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Thenral Socrates
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence University Hospital Basel, Basel, Switzerland
| | - Katarzyna Stolarz-Skrzypek
- 1st Department of Cardiology, Interventional Electrocardiology, and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Renata Cífková
- Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer University Hospital
- Department of Medicine II, Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic
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Montgomery-Csobán T, Kavanagh K, Murray P, Robertson C, Barry SJE, Vivian Ukah U, Payne BA, Nicolaides KH, Syngelaki A, Ionescu O, Akolekar R, Hutcheon JA, Magee LA, von Dadelszen P. Machine learning-enabled maternal risk assessment for women with pre-eclampsia (the PIERS-ML model): a modelling study. Lancet Digit Health 2024; 6:e238-e250. [PMID: 38519152 PMCID: PMC10983826 DOI: 10.1016/s2589-7500(23)00267-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/27/2023] [Accepted: 12/14/2023] [Indexed: 03/24/2024]
Abstract
BACKGROUND Affecting 2-4% of pregnancies, pre-eclampsia is a leading cause of maternal death and morbidity worldwide. Using routinely available data, we aimed to develop and validate a novel machine learning-based and clinical setting-responsive time-of-disease model to rule out and rule in adverse maternal outcomes in women presenting with pre-eclampsia. METHODS We used health system, demographic, and clinical data from the day of first assessment with pre-eclampsia to predict a Delphi-derived composite outcome of maternal mortality or severe morbidity within 2 days. Machine learning methods, multiple imputation, and ten-fold cross-validation were used to fit models on a development dataset (75% of combined published data of 8843 patients from 11 low-income, middle-income, and high-income countries). Validation was undertaken on the unseen 25%, and an additional external validation was performed in 2901 inpatient women admitted with pre-eclampsia to two hospitals in south-east England. Predictive risk accuracy was determined by area-under-the-receiver-operator characteristic (AUROC), and risk categories were data-driven and defined by negative (-LR) and positive (+LR) likelihood ratios. FINDINGS Of 8843 participants, 590 (6·7%) developed the composite adverse maternal outcome within 2 days, 813 (9·2%) within 7 days, and 1083 (12·2%) at any time. An 18-variable random forest-based prediction model, PIERS-ML, was accurate (AUROC 0·80 [95% CI 0·76-0·84] vs the currently used logistic regression model, fullPIERS: AUROC 0·68 [0·63-0·74]) and categorised women into very low risk (-LR <0·1; eight [0·7%] of 1103 women), low risk (-LR 0·1 to 0·2; 321 [29·1%] women), moderate risk (-LR >0·2 and +LR <5·0; 676 [61·3%] women), high risk (+LR 5·0 to 10·0, 87 [7·9%] women), and very high risk (+LR >10·0; 11 [1·0%] women). Adverse maternal event rates were 0% for very low risk, 2% for low risk, 5% for moderate risk, 26% for high risk, and 91% for very high risk within 48 h. The 2901 women in the external validation dataset were accurately classified as being at very low risk (0% with outcomes), low risk (1%), moderate risk (4%), high risk (33%), or very high risk (67%). INTERPRETATION The PIERS-ML model improves identification of women with pre-eclampsia who are at lowest and greatest risk of severe adverse maternal outcomes within 2 days of assessment, and can support provision of accurate guidance to women, their families, and their maternity care providers. FUNDING University of Strathclyde Diversity in Data Linkage Centre for Doctoral Training, the Fetal Medicine Foundation, The Canadian Institutes of Health Research, and the Bill & Melinda Gates Foundation.
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Affiliation(s)
| | - Kimberley Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - Paul Murray
- Department of Electronic and Electrical Engineering, University of Strathclyde, Glasgow, UK
| | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - Sarah J E Barry
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - U Vivian Ukah
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
| | - Beth A Payne
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Kypros H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - Argyro Syngelaki
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - Olivia Ionescu
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK; Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
| | - Ranjit Akolekar
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK; Institute of Medical Sciences, Canterbury Christ Church University, Chatham, UK
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Institute of Women and Children's Health, University of British Columbia, Vancouver, BC, Canada
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London UK
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London UK.
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Mayrink J, Reis ZSN. Pre-eclampsia in low and middle-income settings: What are the barriers to improving perinatal outcomes and evidence-based recommendations? Int J Gynaecol Obstet 2024; 164:33-39. [PMID: 37329226 DOI: 10.1002/ijgo.14913] [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: 02/27/2023] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To discuss the points that still challenge low- and middle-income countries (LMICs) and strategies that have been studied to help them overcome these issues. METHODS Narrative review addressing 20 years of articles concerning pre-eclampsia morbidity and mortality in LMICs. We summarized evidence-based strategies to overcome the challenges in order to reduce the pre-eclampsia impact on perinatal outcomes. RESULTS Pre-eclampsia is the first or second leading cause in the ranking of avoidable causes of maternal death, and approximately 16% of all maternal deaths are attributable to eclampsia and pre-eclampsia. Considering the social and economic contexts, it represents a major public health concern, and prevention and early detection of pre-eclampsia seem to be a major challenge. Reducing maternal mortality related to hypertensive disturbances depends on public policies to manage these preventable conditions. Early and continuous recognition of signs of severity related to hypertensive disorders during pregnancy and childbirth, self-monitoring of symptoms and blood pressure, as well as preventive approaches such as aspirin and calcium, and magnesium sulfate, are lifesaving procedures that have not yet reached a universal scale. CONCLUSION This review provides a vision of relevant points to support pregnant women in overcoming the constraints to healthcare access in LMICs, and strategies that can be applied in primary prenatal care units.
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Affiliation(s)
- Jussara Mayrink
- Federal University of Minas Gerais, Department of Obstetrics and Gynecology, Belo Horizonte, Brazil
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Preeclampsia: Narrative review for clinical use. Heliyon 2023; 9:e14187. [PMID: 36923871 PMCID: PMC10009735 DOI: 10.1016/j.heliyon.2023.e14187] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023] Open
Abstract
Aim Preeclampsia is a very complex multisystem disorder characterized by mild to severe hypertension. Methods PubMed and the Cochrane Library were searched from January 1, 2002 to March 31, 2022, with the search terms "pre-eclampsia" and "hypertensive disorders in pregnancy". We also look for guidelines from international societies and clinical specialty colleges and we focused on publications made after 2015. Results The primary issue associated with this physiopathology is a reduction in utero-placental perfusion and ischemia. Preeclampsia has a multifactorial genesis, its focus in prevention consists of the identification of high and moderate-risk clinical factors. The clinical manifestations of preeclampsia vary from asymptomatic to fatal complications for both the fetus and the mother. In severe cases, the mother may present renal, neurological, hepatic, or vascular disease. The main prevention strategy is the use of aspirin at low doses, started from the beginning to the end of the second trimester and maintained until the end of pregnancy. Conclusion Preeclampsia is a multisystem disorder; we do not know how to predict it accurately. Acetylsalicylic acid at low doses to prevent a low percentage, especially in patients with far from term preeclampsia. There is evidence that exercising for at least 140 min per week reduces gestational hypertension and preeclampsia. Currently, the safest approach is the termination of pregnancy. It is necessary to improve the prediction and prevention of preeclampsia, in addition, better research is needed in the long-term postpartum follow-up.
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Stepan H, Galindo A, Hund M, Schlembach D, Sillman J, Surbek D, Vatish M. Clinical utility of sFlt-1 and PlGF in screening, prediction, diagnosis and monitoring of pre-eclampsia and fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:168-180. [PMID: 35816445 DOI: 10.1002/uog.26032] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/31/2022] [Accepted: 06/08/2022] [Indexed: 05/27/2023]
Abstract
Pre-eclampsia (PE) is characterized by placental and maternal endothelial dysfunction, and associated with fetal growth restriction (FGR), placental abruption, preterm delivery and stillbirth. The angiogenic factors soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) are altered in pregnancies complicated by placenta-related disorders. In this Review, we summarize the existing knowledge, examining the performance of maternal PlGF, sFlt-1 and the sFlt-1/PlGF ratio for screening PE, predicting development of PE in the short term, diagnosing PE, monitoring established PE and predicting other placenta-related disorders in singleton pregnancy. We also discuss the performance of PlGF and the sFlt-1/PlGF ratio for predicting PE in twin pregnancy. For first-trimester screening in singleton pregnancy, a more accurate way of identifying high-risk women than current practice is to combine maternal PlGF levels with clinical risk factors and ultrasound markers. Later in pregnancy, the sFlt-1/PlGF ratio has advantages over PlGF because it has a higher pooled sensitivity and specificity for diagnosing and monitoring PE. It has clinical value because it can rule out the development of PE in the 1-4-week period after the test. Once a diagnosis of PE is established, repeat measurement of sFlt-1 and PlGF can help monitor progression of the condition and may inform clinical decision-making regarding the optimal time for delivery. The sFlt-1/PlGF ratio is useful for predicting FGR and preterm delivery, but the association between stillbirth and the angiogenic factors is unclear. The sFlt-1/PlGF ratio can be used to predict PE in twin pregnancy, although different sFlt-1/PlGF ratio cut-offs from those for singleton pregnancy should be applied for optimal performance. In summary, PlGF, sFlt-1 and the sFlt-1/PlGF ratio are useful for screening, diagnosing, predicting and monitoring placenta-related disorders in singleton and twin pregnancy. We propose that tests for these angiogenic factors are integrated more fully into clinical practice.© 2022 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)
- H Stepan
- University Hospital Leipzig, Leipzig, Germany
| | - A Galindo
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | - M Hund
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | | | - J Sillman
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | - D Surbek
- University Hospital, University of Bern, Bern, Switzerland
| | - M Vatish
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
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Swart RR, Fijten R, Boersma LJ, Kalendralis P, Behrendt MD, Ketelaars M, Roumen C, Jacobs MJG. External validation of a prediction model for timely implementation of innovations in radiotherapy. Radiother Oncol 2023; 179:109459. [PMID: 36608771 DOI: 10.1016/j.radonc.2022.109459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 12/02/2022] [Accepted: 12/28/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to externally validate a model that predicts timely innovation implementation, which can support radiotherapy professionals to be more successful in innovation implementation. MATERIALS AND METHODS A multivariate prediction model was built based on the TRIPOD (Transparent Reporting of a multivariate prediction model for Individual Prognosis Or Diagnosis) criteria for a type 4 study (1). The previously built internally validated model had an AUC of 0.82, and was now validated using a completely new multicentre dataset. Innovation projects that took place between 2017-2019 were included in this study. Semi-structured interviews were performed to retrieve the prognostic variables of the previously built model. Projects were categorized according to the size of the project; the success of the project and thepresence of pre-defined success factors were analysed. RESULTS Of the 80 included innovation projects (32.5% technological, 35% organisational and 32.5% treatment innovations), 55% were successfully implemented within the planned timeframe. Comparing the outcome predictions with the observed outcomes of all innovations resulted in an AUC of the external validation of the prediction model of 0.72 (0.60-0.84, 95% CI). Factors related to successful implementation included in the model are sufficient and competent employees, desirability and feasibility, clear goals and processes and the complexity of a project. CONCLUSION For the first time, a prediction model focusing on the timely implementation of innovations has been successfully built and externally validated. This model can now be widely used to enable more successful innovation in radiotherapy.
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Affiliation(s)
- Rachelle R Swart
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - Rianne Fijten
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Liesbeth J Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Petros Kalendralis
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Myra D Behrendt
- Tilburg School of Economics and Management, Tilburg University, Tilburg, The Netherlands
| | - Martijn Ketelaars
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cheryl Roumen
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Maria J G Jacobs
- Tilburg School of Economics and Management, Tilburg University, Tilburg, The Netherlands
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Thadhani R, Lemoine E, Rana S, Costantine MM, Calsavara VF, Boggess K, Wylie BJ, Moore Simas TA, Louis JM, Espinoza J, Gaw SL, Murtha A, Wiegand S, Gollin Y, Singh D, Silver RM, Durie DE, Panda B, Norwitz ER, Burd I, Plunkett B, Scott RK, Gaden A, Bautista M, Chang Y, Diniz MA, Karumanchi SA, Kilpatrick S. Circulating Angiogenic Factor Levels in Hypertensive Disorders of Pregnancy. NEJM EVIDENCE 2022; 1:EVIDoa2200161. [PMID: 38319832 DOI: 10.1056/evidoa2200161] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Among women with hypertensive disorders of pregnancy, biomarkers may stratify risk for developing preeclampsia with severe features (sPE). METHODS: Across 18 U.S. centers, we prospectively measured the ratio of serum soluble fms-like tyrosine kinase 1 (sFlt-1) to placental growth factor (PlGF) in pregnant women hospitalized between 23 and 35 weeks of gestation. The primary outcome was predicting sPE, and secondary outcomes included predicting adverse outcomes within 2 weeks. The prognostic performance of the sFlt-1:PlGF ratio was assessed by using a derivation/validation design. RESULTS: A total of 1014 pregnant women were evaluated; 299 were included in the derivation cohort and 715 in the validation cohort. In the derivation cohort, the median sFlt-1:PlGF ratio was 200 (interquartile range, 53 to 458) among women who developed sPE compared with 6 (interquartile range, 3 to 26) in those who did not (P<0.001). The discriminatory ratio of ≥40 was then tested in the validation cohort and yielded a 65% positive (95% confidence interval [CI], 59 to 71) and a 96% negative (95% CI, 93 to 98) predictive value for the primary outcome. The ratio performed better than standard clinical measures (area under the receiver-operating characteristic curve, 0.92 versus <0.75 for standard-of-care tests). Compared with women with a ratio <40, women with a ratio ≥40 were at higher risk for adverse maternal outcomes (16.1% versus 2.8%; relative risk, 5.8; 95% CI, 2.8 to 12.2). CONCLUSIONS: In women with a hypertensive disorder of pregnancy presenting between 23 and 35 weeks of gestation, measurement of serum sFlt-1:PlGF provided stratification of the risk of progressing to sPE within the coming fortnight. (Funded by Cedars-Sinai Medical Center and Thermo Fisher Scientific; ClinicalTrials.gov NCT03815110.)
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Affiliation(s)
- Ravi Thadhani
- Cedars-Sinai Medical Center, Los Angeles
- Massachusetts General Hospital, Boston
| | - Elizabeth Lemoine
- Cedars-Sinai Medical Center, Los Angeles
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Sarosh Rana
- University of Chicago Medical Center, Chicago
| | | | | | - Kim Boggess
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | | | | | | | - Jimmy Espinoza
- Baylor College of Medicine and Texas Children's Hospital, Houston
| | | | - Amy Murtha
- University of California at San Francisco, San Francisco
| | | | - Yvonne Gollin
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA
| | | | | | | | | | - Errol R Norwitz
- Tufts Medical Center, Boston
- Newton-Wellesley Hospital, Newton, MA
| | | | | | | | - Anna Gaden
- Cedars-Sinai Medical Center, Los Angeles
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9
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Ukah UV, Platt RW, Auger N, Dasgupta K, Dayan N. Development and internal validation of a model to predict type 2 diabetic complications after gestational diabetes. Sci Rep 2022; 12:10377. [PMID: 35726008 PMCID: PMC9209541 DOI: 10.1038/s41598-022-14215-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Gestational diabetes mellitus (GDM) increases the risk of early-onset type 2 diabetes, which further exacerbates the risk of developing diabetic complications such as kidney, circulatory, and neurological complications. Yet, existing models have solely focused on the prediction of type 2 diabetes, and not of its complications, which are arguably the most clinically relevant outcomes. Our aim was to develop a prediction model for type 2 diabetic complications in patients with GDM. Using provincial administrative data from Quebec, Canada, we developed a model to predict type 2 diabetic complications within 10 years among 90,143 women with GDM. The model was internally validated and assessed for discrimination, calibration, and risk stratification accuracy. The incidence of diabetic complications was 3.8 (95% confidence interval (CI) 3.4-4.3) per 10,000 person-years. The final prediction model included maternal age, socioeconomic deprivation, substance use disorder, gestational age at delivery, severe maternal morbidity, previous pregnancy complications, and hypertensive disorders of pregnancy. The model had good discrimination [area under the curve (AUROC) 0.72 (95% CI 0.69-0.74)] and calibration (slope ≥ 0.9) to predict diabetic complications. In the highest category of the risk stratification table, the positive likelihood ratio was 8.68 (95% CI 4.14-18.23), thereby showing a moderate ability to identify women at highest risk of developing type 2 diabetic complications. Our model predicts the risk of type 2 diabetic complications with moderate accuracy and, once externally validated, may prove to be a useful tool in the management of women after GDM.
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Affiliation(s)
- Ugochinyere Vivian Ukah
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Institut National de Santé Publique du Québec, Montreal, QC, Canada
| | - Robert W Platt
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Nathalie Auger
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Institut National de Santé Publique du Québec, Montreal, QC, Canada
- University of Montreal Hospital Research Centre, Montreal, QC, Canada
- Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada
| | - Kaberi Dasgupta
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Natalie Dayan
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada.
- Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal, QC, Canada.
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Kusuma RA, Nurdiati DS, Wilopo SA. Alternatives of Risk Prediction Models for Preeclampsia in a Low Middle-Income Setting. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract
Objectives: To develop prediction models for the first-trimester prediction of PE (PE) using the established biomarkers including maternal characteristics and history, mean arterial pressure (MAP), uterine artery Doppler pulsatility index (UtA-PI ), and Placental Growth Factor (PlGF)) in combination with Ophthalmic artery Doppler peak ratio (PR).
Methods: This was a prospective observational study in women attending a first-trimester screening at 11-14 weeks’ gestation. Maternal characteristics and history, measurement of MAP, ultrasound examination for UtA-PI measurement, maternal ophthalmic PR Doppler measurement, and serum PlGF collection were performed during the visit. Logistic regression analysis was used to determine if the maternal factor had a significant contribution in predicting PE. The Receiving Operator Curve (ROC) analysis was used to determine the area under the curve (AUC), positive predictive value (PPV), negative prefictive value (NPV) and positive screening cut-off in predicting the occurrence of PE at any gestational age.
Results: Of the 946 eligible participants, 71 (7,49%) subjects were affected by PE. Based on the ROC curves, optimal high-risk cutoff value for prediction of preeclampsia at any gestational age for model 2 (primary care model) in this Indonesia study population were 63% with the sensitivity and specificity of 71.8% and 71.2%, respectively. Both sensitivity and specificity for model 3 (complete model) were 70.4% and 74.9%, respectively for the cutoff value 58%. The area under the curve of model 2, model 3 was 0.7651 (95% CI: 0.7023-0.8279)) and 0.7911 (95% CI: 0.7312-0.8511), respectively, for predicting PE. In addition, PPV and NPV for model 2 were 16.8% and 96.9%, respectively. PPV and NPV for model 3 were 18.55 and 96.9%, respectively.
Conclusion: The prediction models of preeclampsia vary depending upon healthcare resource. Complete model is clinically superior to primary care model but it is not statistically significant. Prognostic models should be easy to use, informative and low cost with great potential to improve maternal and neonatal health in Low Middle Income Country settings.
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Affiliation(s)
- Laura A Magee
- From the Department of Women and Children's Health, School of Life Course Sciences, King's College London (L.A.M., K.H.N., P.D.), the Institute of Women and Children's Health, King's Health Partners Academic Health Science Centre (L.A.M., P.D.), and the Harris Birthright Research Centre for Fetal Medicine, King's College Hospital (K.H.N.) - all in London
| | - Kypros H Nicolaides
- From the Department of Women and Children's Health, School of Life Course Sciences, King's College London (L.A.M., K.H.N., P.D.), the Institute of Women and Children's Health, King's Health Partners Academic Health Science Centre (L.A.M., P.D.), and the Harris Birthright Research Centre for Fetal Medicine, King's College Hospital (K.H.N.) - all in London
| | - Peter von Dadelszen
- From the Department of Women and Children's Health, School of Life Course Sciences, King's College London (L.A.M., K.H.N., P.D.), the Institute of Women and Children's Health, King's Health Partners Academic Health Science Centre (L.A.M., P.D.), and the Harris Birthright Research Centre for Fetal Medicine, King's College Hospital (K.H.N.) - all in London
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12
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Magee LA, Smith GN, Bloch C, Côté AM, Jain V, Nerenberg K, von Dadelszen P, Helewa M, Rey E. Directive clinique n o 426 : Troubles hypertensifs de la grossesse : Diagnostic, prédiction, prévention et prise en charge. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:572-597.e1. [PMID: 35577427 DOI: 10.1016/j.jogc.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIF La présente directive a été élaborée par des fournisseurs de soins de maternité en obstétrique et en médecine interne. Elle aborde le diagnostic, l'évaluation et la prise en charge des troubles hypertensifs de la grossesse, la prédiction et la prévention de la prééclampsie ainsi que les soins post-partum des femmes avec antécédent de trouble hypertensif de la grossesse. POPULATION CIBLE Femmes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en œuvre des recommandations de la présente directive devrait réduire l'incidence des troubles hypertensifs de la grossesse, en particulier la prééclampsie, et des issues défavorables associées. DONNéES PROBANTES: La revue exhaustive de la littérature a été mise à jour en tenant compte des nouvelles données probantes jusqu'en décembre 2020 et en suivant la même méthodologie que pour la précédente directive de la Société des obstétriciens et gynécologues du Canada (SOGC) sur les troubles hypertensifs de la grossesse. La recherche s'est limitée aux articles publiés en anglais ou en français. Les recommandations relatives aux traitements s'appuient d'abord sur les essais cliniques randomisés et les revues systématiques (lorsque disponibles), ainsi que sur l'évaluation des résultats cliniques substantiels chez les mères et les bébés. MéTHODES DE VALIDATION: Les auteurs se sont entendus sur le contenu et les recommandations par consensus et ont répondu à l'examen par les pairs du comité de médecine fœto-maternelle de la SOGC. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE) et se sont gardé l'option de désigner certaines recommandations par la mention « bonne pratique ». Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication. PROFESSIONNELS CIBLES Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières et anesthésistes) qui prodiguent des soins aux femmes avant, pendant ou après la grossesse. RECOMMANDATIONS
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13
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Magee LA, Smith GN, Bloch C, Côté AM, Jain V, Nerenberg K, von Dadelszen P, Helewa M, Rey E. Guideline No. 426: Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:547-571.e1. [PMID: 35577426 DOI: 10.1016/j.jogc.2022.03.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This guideline was developed by maternity care providers from obstetrics and internal medicine. It reviews the diagnosis, evaluation, and management of the hypertensive disorders of pregnancy (HDPs), the prediction and prevention of preeclampsia, and the postpartum care of women with a previous HDP. TARGET POPULATION Pregnant women. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in these guidelines may reduce the incidence of the HDPs, particularly preeclampsia, and associated adverse outcomes. EVIDENCE A comprehensive literature review was updated to December 2020, following the same methods as for previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines, and references were restricted to English or French. To support recommendations for therapies, we prioritized randomized controlled trials and systematic reviews (if available), and evaluated substantive clinical outcomes for mothers and babies. VALIDATION METHODS The authors agreed on the content and recommendations through consensus and responded to peer review by the SOGC Maternal Fetal Medicine Committee. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication. INTENDED USERS All health care providers (obstetricians, family doctors, midwives, nurses, and anesthesiologists) who provide care to women before, during, or after pregnancy. RECOMMENDATIONS
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14
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Magee LA, Brown MA, Hall DR, Gupte S, Hennessy A, Karumanchi SA, Kenny LC, McCarthy F, Myers J, Poon LC, Rana S, Saito S, Staff AC, Tsigas E, von Dadelszen P. The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2022; 27:148-169. [DOI: 10.1016/j.preghy.2021.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
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15
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Development and external validation of a model for predicting adverse outcomes in women with preeclampsia: A retrospective study from two trans-regional centers in China. Pregnancy Hypertens 2021; 26:133-140. [PMID: 34794010 DOI: 10.1016/j.preghy.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/12/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Preeclampsia is a common complication of pregnancy that causes health problems for both the mother and her fetus. This study aimed to develop and externally validate a model to predict adverse outcomes in preeclampsia in a trans-regional two-center retrospective cohort of Chinese women. STUDY DESIGN To generate a model for the risk of women with adverse outcomes, we incorporated candidate variables in the development set in univariate, least absolute shrinkage and selection operator analysis and multivariable logistic regression. The performance of the model was evaluated for the receiver operating characteristic (ROC) curve, calibration and decision curve analysis. Further, we externally validated the model in an independent dataset. MAIN OUTCOME MEASURES Composite adverse outcomes within 48 h of admission. RESULTS There were 1 783 and 116 preeclampsia women in the development and validation set, respectively. The model included 10 predictors: gestational age at admission, irregular prenatal care, number of symptoms, mean arterial pressure, hematocrit, platelet count, fibrinogen, albumin, total bilirubin, and serum urea. The area under the ROC curve of the model was 0.867 in the development set and 0.841 in the external validation set. The calibration plots for the probability of adverse outcomes demonstrated a good correlation. Decision curve analysis further showed that our model had clinical application value. The nomogram and a software-based calculator (https://sdfyyfck.shinyapps.io/preeclampsia/) were constructed for convenient clinical use. CONCLUSIONS Such a model could be used as a useful tool for the assessment of hypertensive-related complications in Chinese preeclampsia patients.
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Poon LC, Magee LA, Verlohren S, Shennan A, von Dadelszen P, Sheiner E, Hadar E, Visser G, Da Silva Costa F, Kapur A, McAuliffe F, Nazareth A, Tahlak M, Kihara AB, Divakar H, McIntyre HD, Berghella V, Yang H, Romero R, Nicolaides KH, Melamed N, Hod M. A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre-eclampsia: Compiled by the Pregnancy and Non-Communicable Diseases Committee of FIGO (the International Federation of Gynecology and Obstetrics). Int J Gynaecol Obstet 2021; 154 Suppl 1:3-31. [PMID: 34327714 PMCID: PMC9290930 DOI: 10.1002/ijgo.13763] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Laura A Magee
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Andrew Shennan
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology B, Soroka University Medical Center, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gerard Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - Fabricio Da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Anil Kapur
- World Diabetes Foundation, Bagsvaerd, Denmark
| | - Fionnuala McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Amala Nazareth
- Jumeira Prime Healthcare Group, Emirates Medical Association, Dubai, United Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and Children, Dubai Health Authority, Emirates Medical Association, Mohammed Bin Rashid University for Medica Sciences, Dubai, United Arab Emirates
| | - Anne B Kihara
- African Federation of Obstetricians and Gynaecologists, Khartoum, Sudan
| | | | - H David McIntyre
- University of Queensland Mater Clinical School, Brisbane, Queensland, Australia
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
| | | | - Nir Melamed
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Moshe Hod
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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von Dadelszen P, Vidler M, Tsigas E, Magee LA. Management of Preeclampsia in Low- and Middle-Income Countries: Lessons to Date, and Questions Arising, from the PRE-EMPT and Related Initiatives. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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18
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Lappen JR, Pettker CM, Louis JM, Louis JM. Society for Maternal-Fetal Medicine Consult Series #54: Assessing the risk of maternal morbidity and mortality. Am J Obstet Gynecol 2021; 224:B2-B15. [PMID: 33309560 DOI: 10.1016/j.ajog.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.
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Affiliation(s)
| | | | | | - Judette M Louis
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Hurrell A, Duhig K, Vandermolen B, Shennan AH. Recent advances in the diagnosis and management of pre-eclampsia. Fac Rev 2021; 9:10. [PMID: 33659942 PMCID: PMC7886065 DOI: 10.12703/b/9-10] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Pre-eclampsia is an elusive condition to diagnose and a complex disease to manage. There have been recent developments in prediction, prevention, diagnosis, and management. Risk modelling has been used to identify women at highest risk of developing pre-eclampsia as well as predicting maternal adverse outcomes in confirmed disease. New evidence has shown that aspirin prophylaxis significantly reduces early onset pre-eclampsia as well as preterm birth. The criteria for the diagnosis of pre-eclampsia are evolving, and proteinuria is no longer a pre-requisite to make a diagnosis. Angiogenic biomarker testing accelerates diagnosis as well as minimises adverse maternal outcomes and has been incorporated into national guidelines. Emerging evidence demonstrates that expedited delivery in late preterm pre-eclampsia may be protective against maternal adverse outcomes but increase the risk of neonatal unit admission. Both women and their offspring are at increased risk of long-term health complications following pre-eclampsia, and it is important that postnatal health is optimised. This article summarises recent developments in the field of pre-eclampsia research, evaluating the impact on clinical care for women at risk of, or with suspected or confirmed, pre-eclampsia.
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Affiliation(s)
- Alice Hurrell
- Women's Health Academic Centre, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Kate Duhig
- Women's Health Academic Centre, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Brooke Vandermolen
- Women's Health Academic Centre, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - Andrew H Shennan
- Women's Health Academic Centre, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
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20
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Wiles K, Webster P, Seed PT, Bennett-Richards K, Bramham K, Brunskill N, Carr S, Hall M, Khan R, Nelson-Piercy C, Webster LM, Chappell LC, Lightstone L. The impact of chronic kidney disease Stages 3-5 on pregnancy outcomes. Nephrol Dial Transplant 2020; 36:2008-2017. [PMID: 33313680 PMCID: PMC8577624 DOI: 10.1093/ndt/gfaa247] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 12/16/2022] Open
Abstract
Background Contemporaneous data are required for women with chronic kidney disease (CKD) Stages 3–5 to inform pre-pregnancy counselling and institute appropriate antenatal surveillance. Methods A retrospective cohort study in women with CKD Stages 3–5 after 20 weeks’ gestation was undertaken in six UK tertiary renal centres in the UK between 2003 and 2017. Factors predicting adverse outcomes and the impact of pregnancy in accelerating the need for renal replacement therapy (RRT) were assessed. Results There were 178 pregnancies in 159 women, including 43 women with renal transplants. The live birth rate was 98%, but 56% of babies were born preterm (before 37 weeks’ gestation). Chronic hypertension was the strongest predictor of delivery before 34 weeks’ gestation. Of 121 women with known pre-pregnancy hypertension status, the incidence of delivery before 34 weeks was 32% (31/96) in women with confirmed chronic hypertension compared with 0% (0/25) in normotensive women. The risk of delivery before 34 weeks doubled in women with chronic hypertension from 20% [95% confidence interval (CI) 9–36%] to 40% (95% CI 26–56%) if the gestational fall in serum creatinine was <10% of pre-pregnancy concentrations. Women with a urinary protein:creatinine ratio >100 mg/mmol prior to pregnancy or before 20 weeks’ gestation had an increased risk for birthweight below the 10th centile (odds ratio 2.57, 95% CI 1.20–5.53). There was a measurable drop in estimated glomerular filtration rate (eGFR) between pre-pregnancy and post-partum values (4.5 mL/min/1.73 m2), which was greater than the annual decline in eGFR prior to pregnancy (1.8 mL/min/1.73 m2/year). The effect of pregnancy was, therefore, equivalent to 1.7, 2.1 and 4.9 years of pre-pregnancy renal disease in CKD Stages 3a, 3b and 4–5, respectively. The pregnancy-associated decline in renal function was greater in women with chronic hypertension and in those with a gestational fall in serum creatinine of <10% of pre-pregnancy concentrations. At 1 year post-partum, 46% (58/126) of women had lost ≥25% of their pre-pregnancy eGFR or required RRT. Most women with renal transplants had CKD Stage 3 and more stable renal function prior to pregnancy. Renal transplantation was not independently associated with adverse obstetric or renal outcomes. Conclusions Contemporary pregnancies in women with CKD Stages 3–5 are complicated by preterm delivery, low birthweight and loss of maternal renal function. Chronic hypertension, pre- or early pregnancy proteinuria and a gestational fall in serum creatinine of <10% of pre-pregnancy values are more important predictors of adverse obstetric and renal outcome than CKD Stages 3–5. Pregnancy in women with CKD Stages 3–5 advances the need for dialysis or transplantation by 2.5 years.
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Affiliation(s)
- Kate Wiles
- Department of Women and Children's Health, Kings College London, London, UK
| | | | - Paul T Seed
- Department of Women and Children's Health, Kings College London, London, UK
| | | | - Kate Bramham
- Department of Women and Children's Health, Kings College London, London, UK.,King's Kidney Care, King's College NHS Foundation Trust, London, UK
| | - Nigel Brunskill
- Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Sue Carr
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Matt Hall
- Department of Renal Medicine, Nottingham University Hospitals NHS Trust, Leicester, UK
| | - Rehan Khan
- Department of Obstetrics and Gynaecology, Barts Health NHS Trust and Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, London, UK
| | - Catherine Nelson-Piercy
- Department of Women and Children's Health, Kings College London, London, UK.,Department of Obstetric Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Louise M Webster
- Department of Women and Children's Health, Kings College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, Kings College London, London, UK
| | - Liz Lightstone
- Imperial College Healthcare NHS Trust, London, UK.,Centre for Inflammatory Disease, Faculty of Medicine, Imperial College London, London, UK
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Guida JP, Cralcev C, Costa Santos J, Marangoni-Junior M, Sanchez MP, Laura Costa M. Validation of the fullPIERS model for prediction of adverse outcomes in preeclampsia at a referral center. Pregnancy Hypertens 2020; 23:112-115. [PMID: 33310390 DOI: 10.1016/j.preghy.2020.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 11/21/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To validate the use of fullPIERS to predict maternal and perinatal adverse outcomes in a referral center. METHODS Cross-sectional study including all pregnant women with preeclampsia (PE) at a referral center in southeast Brazil. The prevalence of PE and adverse outcomes were assessed. The fullPIERS score was tested on three composites of adverse outcomes: maternal adverse outcome; fetal adverse outcomes; and the combination of these two. Furthermore, the fullPIERS risk calculator, was considered to define the cutoff that better estimates adverse outcomes. RESULTS 2839 women were screened in a one year period, with 208 (7.3%) cases of PE; most were preterm (56.7%); with severe features (74.5%). HELLP syndrome (6.7%), eclampsia (3.8%) and placental abruption (2.4%) were the most frequent complications. FullPIERS assessement had a median of 1.2% (0.45 - 2.3%) and the score had an excelent performance to predict adverse maternal outcome (AUC = 0.845, confidence interval 0.776 - 0.914, p-value < 0.01). For perinatal adverse outcomes (AUC = 0.699, confidence interval 0.581 - 0.816, p-value < 0.01) and the composite of maternal and perinatal adverse outcome (AUC = 0.804, confidence interval 0.736 - 0.872, p-vale < 0.01), fullPIERS score had a suboptimal performance. The cutoff value that best performed for the assessment of maternal adverse outcome was 2.15% (sensitivity of 75% and specificity of 83%). CONCLUSION Preeclampsia was a significant complication during pregnancy. The fullPIERS model was an excellent tool to predict maternal adverse outcomes; with a cutoff value of 2.15% in the tested population.
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Affiliation(s)
| | - Christopher Cralcev
- Department of Obstetrics and Gynecology, University of Campinas, Campinas, Brazil
| | - Juliana Costa Santos
- Department of Obstetrics and Gynecology, University of Campinas, Campinas, Brazil
| | | | | | - Maria Laura Costa
- Department of Obstetrics and Gynecology, University of Campinas, Campinas, Brazil.
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22
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Ukah UV, Payne BA, Hutcheon JA, Chappell LC, Seed PT, Conti-Ramsden FI, Ansermino JM, Magee LA, von Dadelszen P. Placental growth factor for the prognosis of women with preeclampsia (fullPIERS model extension): context matters. BMC Pregnancy Childbirth 2020; 20:668. [PMID: 33153436 PMCID: PMC7643272 DOI: 10.1186/s12884-020-03332-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/09/2020] [Indexed: 12/12/2022] Open
Abstract
Background The fullPIERS risk prediction model was developed to identify which women admitted with confirmed diagnosis of preeclampsia are at highest risk of developing serious maternal complications. The model discriminates well between women who develop (vs. those who do not) adverse maternal outcomes. It has been externally validated in several populations. We assessed whether placental growth factor (PlGF), a biomarker associated with preeclampsia risk, adds incremental value to the fullPIERS model. Methods Using a cohort of women admitted into tertiary hospitals in well-resourced settings (the USA and Canada), between May 2010 to February 2012, we evaluated the incremental value of PlGF added to fullPIERS for prediction of adverse maternal outcomes within 48 h after admission with confirmed preeclampsia. The discriminatory performance of PlGF and the fullPIERS model were assessed in this cohort using the area under the receiver’s operating characteristic curve (AUROC) while the extended model (fullPIERS +PlGF) was assessed based on net reclassification index (NRI) and integrated discrimination improvement (IDI) performances. Results In a cohort of 541 women delivered shortly (< 1 week) after presentation, 8.1% experienced an adverse maternal outcome within 48 h of admission. Prediction of adverse maternal outcomes was not improved by addition of PlGF to fullPIERS (NRI: -8.7, IDI − 0.06). Discriminatory performance (AUROC) was 0.67 [95%CI: 0.59–0.75] for fullPIERS only and 0.67 [95%CI: 0.58–0.76]) for fullPIERS extended with PlGF, a performance worse than previously documented in fullPIERS external validation studies (AUROC > 0.75). Conclusions While fullPIERS model performance may have been affected by differences in healthcare context between this study cohort and the model development and validation cohorts, future studies are required to confirm whether PlGF adds incremental benefit to the fullPIERS model for prediction of adverse maternal outcomes in preeclampsia in settings where expectant management is practiced.
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Affiliation(s)
- U Vivian Ukah
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, H3A 1A2, Canada.
| | - Beth A Payne
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer A Hutcheon
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Frances Inez Conti-Ramsden
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - J Mark Ansermino
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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23
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Dines V, Kattah A. Hypertensive Disorders of Pregnancy. Adv Chronic Kidney Dis 2020; 27:531-539. [PMID: 33328070 DOI: 10.1053/j.ackd.2020.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
Hypertensive disorders of pregnancy are increasing in incidence and are major causes of maternal morbidity and mortality both in the United States and worldwide. An understanding of these diseases is essential for the practicing nephrologist, as preexisting kidney disease is an important risk factor. In addition, the development of hypertensive disorders of pregnancy has important implications for long-term risk of kidney disease and cardiovascular disease. The definition and diagnostic criteria has changed in recent years as our understanding of the disease entity has progressed. Currently, proteinuria is no longer a necessary diagnostic feature of preeclampsia. Preeclampsia and gestational hypertension may develop through multiple different mechanisms. Current research suggests contributions of both placental factors and maternal factors contribute to the disease and represent different phenotypic presentations of preeclampsia.
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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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25
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Blackwell S, Louis JM, Norton ME, Lappen JR, Pettker CM, Kaimal A, Landy U, Edelman A, Teal S, Landis R. Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning. Am J Obstet Gynecol 2020; 222:B2-B18. [PMID: 32252942 DOI: 10.1016/j.ajog.2019.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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26
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Cox AG, Marshall SA, Palmer KR, Wallace EM. Current and emerging pharmacotherapy for emergency management of preeclampsia. Expert Opin Pharmacother 2019; 20:701-712. [PMID: 30707633 DOI: 10.1080/14656566.2019.1570134] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Preeclampsia is a disease specific to pregnancy characterised by new onset hypertension with maternal organ dysfunction and/or fetal growth restriction. It remains a major cause of maternal and perinatal morbidity and mortality. For fifty years, antihypertensives have been the mainstay of treating preeclampsia, reducing maternal morbidity and mortality. With increased knowledge of the mechanisms underlying the disease has come opportunities for novel therapies that complement antihypertensives by protecting the maternal vasculature. Areas covered: In this review, the authors consider, in detail, the antihypertensives commonly used today in the emergency care of women with severe preeclampsia. They also review less common anti-hypertensive agents and discuss the role of magnesium sulphate in the management of preeclampsia and the prevention of eclampsia. Finally, they explore novel therapeutics for the acute management of preeclampsia. Expert opinion: The rapid control of maternal hypertension will, and must, remain the mainstay of emergency treatment for women with severe preeclampsia. The role of magnesium sulphate as a primary prevention for eclampsia is context dependant and should not displace a focus on correcting blood pressure safely. The exploration of novel adjuvant therapies will likely allow us to prolong pregnancy longer and improve perinatal outcomes safely for the mother.
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Affiliation(s)
- Annie G Cox
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia.,b The Ritchie Centre , Hudson Institute of Medical Research , Clayton , Australia
| | - Sarah A Marshall
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia.,b The Ritchie Centre , Hudson Institute of Medical Research , Clayton , Australia
| | - Kirsten R Palmer
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia
| | - Euan M Wallace
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia.,b The Ritchie Centre , Hudson Institute of Medical Research , Clayton , Australia
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