A point-of care urine test to predict preeclampsia development in Asian women with suspected preeclampsia

Predictive value of urine misfolded protein in preeclampsia in twin pregnancies

OBJECTIVE

To assess the utility of urinary misfolded proteins (MP) in predicting preeclampsia (PE) in high-risk twin pregnancies.

METHODS

A prospective study was conducted on 600 high-risk twin pregnancies at Shanghai First Maternity and Infant Hospital from March to August 2021. Clinical data were collected, and urinary MP levels were measured. Subsequently, fetal outcomes were monitored. The patients were categorized into three groups based on the presence of PE: unaffected PE group, early-onset PE (ePE) group (gestational age < 34 weeks), and late-onset PE (lPE) group (gestational age ≥ 34 weeks). The predictive value of MP in PE was evaluated using analysis of variance, Chi-square test, and ROC curve analysis.

RESULTS

A total of 464 twin pregnancies were included in the study, among which 66 cases (14.2%) developed PE, including 19 cases of ePE (4.1%) and 47 cases (10.1%) of lPE. Significant differences were found in maternal age, pre-pregnancy body mass index (BMI), BMI ≥ 28 km/m2, mean systolic blood pressure, diastolic blood pressure, mean arterial pressure (MAP), MAP ≥ 85 mmHg, history of PE, history of chronic hypertension, and positive urine protein. The maternal and fetal complications of twin pregnancies with PE were higher than those without PE (P < 0.05). When maternal factors (MF), MAP, and MP were used to predict ePE and lPE alone, the area under the ROC curve of MF was the largest, at 0.739 (95% CI 0.619-0.860) and 0.692 (95% CI 0.603-0.782), respectively. The area under the ROC curve of the combination of the three factors was 0.770 (95% CI 0.703-0.837), higher than that of a single index. In addition, MP predicted the positive predictive value (PPV) and negative predictive value (NPV) of PE from 12 to 15+6 gestational weeks as 57.9% and 89.2%, respectively; from 16 to 27+6 gestational weeks as 36.2% and 89.9%, respectively; and during the 12-27+6 gestational weeks as 42.4% and 92.2%, respectively.

CONCLUSION

The detection of MP in the urine of women with twin pregnancies is a non-invasive and convenient method for predicting PE. If the test result is positive, enhanced monitoring and timely transfer to a superior hospital are necessary. If the test result is negative, it indicates a low risk of developing PE, reducing the need for excessive clinical examination and intervention.

Validation of urinary Congo Red preeclampsia detection point-of-care devise

OBJECTIVES

To evaluate a commercial a Congo Red urine devise for assessing preeclampsia risk.

STUDY DESIGN

Prospective non-intervention study among women presenting with clinical suspicion of preeclampsia. The devise was used at the time of enrolment and, depending on gestation, on 1-3 later occasions.

OUTCOME MEASURES

Abnormal diffusion patterns classified as positive or negative, in relation to subsequent confirmation of preeclampsia (detection and false-positive rates, and predictive value) and the probability of diagnosis within a fixed time period (rule-in and rule-out).

RESULTS

600 women were enrolled in the study and follow-up information was available on 538, of whom 95 had preeclampsia at delivery and 443 did not. At enrolment the detection rate was 18 % and the false-positive rate 3.2 %; positive predictive value - probability of positive result being associated with preeclampsia - was 55 % and negative predictive value - probability of negative result not being preeclampsia - was 85 %. A positive test ruled-in delivery with preeclampsia within 28 days among 35 % and ruled-out preeclampsia with 7 days among 98 %. Repeat testing after enrolment yielded similar results to the initial sample.

CONCLUSION

The test has screening potential although published studies differ in the observed detection rate. Using the test to rule-out preeclampsia within 7 days can provide a significant management advantage especially for triaging patients and selecting those who can be managed at the peripheral centres.

Intermanufacturer assessment of diagnostic performance of angiogenic ratio vs glycosylated fibronectin in women with suspected pre-eclampsia

OBJECTIVE

To compare the diagnostic performance of different manufacturers' immunoassays for the soluble fms-like tyrosine kinase-1 (sFlt-1)-to-placental growth factor (PlGF) ratio with that of a point-of-care (PoC) test for glycosylated fibronectin (GlyFn) in women with suspected pre-eclampsia (PE).

METHODS

This was a prospective, single-center, double-blinded, non-interventional study of East Asian women with a singleton pregnancy who presented with hypertension with or without clinical features of PE after 20 weeks' gestation between January 2020 and March 2022. Maternal serum samples were collected at the time of presentation, and subsequent management followed the departmental protocol, based on gestational age, severity of hypertension, fetal condition and presence of severe PE features. Women diagnosed with PE at presentation were excluded. PE was diagnosed according to the 2018 International Society for the Study of Hypertension in Pregnancy classification. Levels of sFlt-1 and PlGF were measured using the Cobas e411 (Roche Diagnostics), BRAHMS KRYPTOR (ThermoFisher Scientific) and iMAGIN 1800 (Ningbo Aucheer) platforms. GlyFn levels were measured using the Lumella™ GlyFn PoC test (DiabetOmics Inc.). The predictive performance of each test to rule out PE within 7 days and rule in PE within 28 days from the date of presentation was assessed. Based on the PROGNOSIS study, a sFlt-1/PlGF ratio of ≤ 38 on the Roche platform was used to predict the absence of PE within 7 days. The sFlt-1/PlGF ratio was classified as high or low using platform-specific thresholds equivalent to a Roche sFlt-1/PlGF ratio of 38, which were derived using Passing-Bablok regression. GlyFn was categorized as high or low using two reported clinical management thresholds (263 μg/mL and 510 μg/mL).

RESULTS

Overall, 236 women with suspected PE were included, of whom 70 (29.7%) were diagnosed with PE; 36 (51.4%) and 70 (100%) developed PE within 7 days and 28 days, respectively. Eighty-eight (37.3%) women had a sFlt-1/PlGF ratio of > 38 on the Roche platform, 79 (33.5%) women had a sFlt-1/PlGF ratio of > 55 on the KRYPTOR platform and 96 (40.7%) women had a sFlt-1/PlGF ratio of > 40 on the iMAGIN 1800 platform. Furthermore, 62 (26.3%) and four (1.7%) women had a GlyFn level of > 263 μg/mL and > 510 μg/mL, respectively. The negative predictive value (NPV) of the sFlt-1/PlGF ratio measured on the Roche, KRYPTOR and iMAGIN 1800 platforms to rule out PE within 7 days after presentation was 83.3%, 82.0% and 82.9%, respectively, while that for GlyFn > 263 μg/mL and > 510 μg/mL was 82.6% and 70.4%, respectively. The corresponding positive predictive values (PPV) to rule in PE within 28 days after presentation were 50.5%, 52.3% and 46.7%, respectively, for the sFlt-1/PlGF ratio, and 35.4% and 50.0%, respectively, for GlyFn > 263 μg/mL and > 510 μg/mL.

CONCLUSIONS

The predictive performance of different manufacturers' assays for the sFlt-1/PlGF ratio to rule in and rule out PE were similar once standardized to a common threshold. Our findings suggest that the sFlt-1/PlGF ratio and GlyFn using a cut-off of 263 μg/mL can both be utilized to rule out PE within 7 days after assessment, with a moderate NPV. The PPV for ruling in PE within 28 days remains poor. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A point-of-care urine test to predict adverse maternal and neonatal outcomes in Asian women with suspected preeclampsia

OBJECTIVES

To assess clinical utility of the urine Congo red dot test (CRDT) in predicting composite adverse maternal and neonatal outcomes in women with suspected preeclampsia (PE).

METHODS

CRDT result and pregnancy outcomes were prospectively documented in women with new onset or pre-existing hypertension, new or pre-existing proteinuria, PE symptoms and suspected PE-related fetal growth restriction or abnormal Doppler presenting from 20 weeks' gestation between January 2020 and December 2022. Participants and clinicians were blinded to the CRDT result and managed according to internally agreed protocols. Composite maternal outcome was defined as PE, postpartum hemorrhage, intensive care unit admission, and maternal death. Composite neonatal outcome was defined as small for gestational age, preterm birth, 5-min Apgar score < 7, neonatal intensive care unit admission, and neonatal death.

RESULTS

Two hundred and forty-four women out of two hundred and fifty-one (97.2%) had a negative CRDT. All seven women with positive CRDT had both adverse maternal and neonatal outcomes, giving positive predictive values (PPV) of 100%. Rates of composite adverse maternal and neonatal outcomes in CDRT negative women were 103/244 [42.2%, 95% confidence interval (CI) 36.2%-48.5%] and 170/244 (69.7%, 95% CI 63.6%-75.1%), respectively. CRDT negative predictive values (NPV) for adverse maternal and neonatal outcomes were, respectively, 141/244 (57.8%, 95% CI 48.6%-68.2%) and 74/244 (30.3%, 95% CI 23.8%-38.1%).

CONCLUSION

CRDT had low NPV but high PPV for adverse maternal and neonatal outcomes in women with suspected PE. Its role in clinical management and triage of women with suspected PE is limited as it cannot identify those at low risk of developing adverse outcomes.

Comparing urine point-of-care tests to screen preeclampsia: Congo-red dot paper test versus dipstick urinalysis

To compare the urine Congo-red dot paper test (CRD) with dipstick urinalysis to screen preeclampsia (PE). A total of 409 paired spot urine samples were obtained prospectively from women with suspected pre-eclampsia attending for routine hospital visits. Congo-red dot paper test and dipstick urinalysis were examined and compared to screen pre-eclampsia. The agreement between the two urinary test is modest (kappa coefficient = 0.28, 95% CI 0.14-0.42). The specificity of CRD was higher than urinalysis (97.4% vs. 90.4%, p < .001). Urinalysis performed better in sensitivity (77.3% vs. 40.9%, p = .04) and the area under the receiver operating characteristic curves (AUC) (0.84 [95% CI 0.74-0.94] vs. 0.69 [95% CI 0.55-0.83], p = .04) than CRD, respectively. The sensitivity, specificity, AUC of the parallel test of them is 86.4% (64.0%-96.4%), 89.1% (85.5%-92.0%), and 0.88 (95% CI 0.79-0.96). And the serial test is 31.8% (14.7%-54.9%), 98.7% (96.8%-99.5%), 0.65 (95% CI 0.51-0.79), accordingly. The urinalysis is a better diagnosing test for preeclampsia. CRD could aid in the diagnosis of patients with preeclampsia. Combined the two tests in suspected patients may further improve the performance in the diagnosis of preeclampsia. Further study need to be made for its potential clinical practice.

Protein Misfolding in Pregnancy: Current Insights, Potential Mechanisms, and Implications for the Pathogenesis of Preeclampsia

Protein misfolding disorders are a group of diseases characterized by supra-physiologic accumulation and aggregation of pathogenic proteoforms resulting from improper protein folding and/or insufficiency in clearance mechanisms. Although these processes have been historically linked to neurodegenerative disorders, such as Alzheimer's disease, evidence linking protein misfolding to other pathologies continues to emerge. Indeed, the deposition of toxic protein aggregates in the form of oligomers or large amyloid fibrils has been linked to type 2 diabetes, various types of cancer, and, in more recent years, to preeclampsia, a life-threatening pregnancy-specific disorder. While extensive physiological mechanisms are in place to maintain proteostasis, processes, such as aging, genetic factors, or environmental stress in the form of hypoxia, nutrient deprivation or xenobiotic exposures can induce failure in these systems. As such, pregnancy, a natural physical state that already places the maternal body under significant physiological stress, creates an environment with a lower threshold for aberrant aggregation. In this review, we set out to discuss current evidence of protein misfolding in pregnancy and potential mechanisms supporting a key role for this process in preeclampsia pathogenesis. Improving our understanding of this emerging pathophysiological process in preeclampsia can lead to vital discoveries that can be harnessed to create better diagnoses and treatment modalities for the disorder.