Bilateral notching of uterine arteries at 12-14 weeks of gestation for prediction of hypertensive disorders of pregnancy

Dynamic risk prediction models for different subtypes of hypertensive disorders in pregnancy

Background

Hypertensive disorders in pregnancy (HDP) are diseases that coexist with pregnancy and hypertension. The pathogenesis of this disease is complex, and different physiological and pathological states can develop different subtypes of HDP.

Objective

To investigate the predictive effects of different variable selection and modeling methods on four HDP subtypes: gestational hypertension, early-onset preeclampsia, late-onset preeclampsia, and chronic hypertension complicated with preeclampsia.

Methods

This research was a retrospective study of pregnant women who attended antenatal care and labored at Beijing Maternity Hospital, Beijing Haidian District Maternal and Child Health Hospital, and Peking University People's Hospital. We extracted maternal demographic data and clinical characteristics for risk factor analysis and included gestational week as a parameter in this study. Finally, we developed a dynamic prediction model for HDP subtypes by nonlinear regression, support vector machine, stepwise regression, and Lasso regression methods.

Results

The AUCs of the Lasso regression dynamic prediction model for each subtype were 0.910, 0.962, 0.859, and 0.955, respectively. The AUC of the Lasso regression dynamic prediction model was higher than those of the other three prediction models. The accuracy of the Lasso regression dynamic prediction model was above 85%, and the highest was close to 92%. For the four subgroups, the Lasso regression dynamic prediction model had the best comprehensive performance in clinical application. The placental growth factor was tested significant (P < 0.05) only in the stepwise regression dynamic prediction model for early-onset preeclampsia.

Conclusion

The Lasso regression dynamic prediction model could accurately predict the risk of four HDP subtypes, which provided the appropriate guidance and basis for targeted prevention of adverse outcomes and improved clinical care.

A Review of Roles of Uterine Artery Doppler in Pregnancy Complications

The invasion of trophoblasts into the uterine decidua and decidual vessels is critical for the formation of placenta. The defects of placentation are related to the etiologies of preeclampsia (PE), fetal growth restriction (FGR), and small-for-gestational age (SGA) neonates. It is possible to predict significant vascular events during pregnancy through uterine artery Doppler (UAD). From the implantation stage to the end of pregnancy, detecting changes in uterine and placental blood vessels can provide a favorable diagnostic instrument for pregnancy complications. This review aims to collect literature about the roles of UAD in pregnancy complications. We consider all relevant articles in English from January 1, 1983 to October 30, 2021. Predicting pregnancy complications in advance allows practitioners to carry out timely interventions to avoid or lessen the harm to mothers and neonates. Administering low-dose aspirin daily before 16 weeks of pregnancy can significantly reduce the incidence of pregnancy complications. From early pregnancy to late pregnancy, UAD can combine with other maternal factors, biochemical indicators, and fetal measurement data to identify high-risk population. The identification of high-risk groups can also lessen maternal mortality. Besides, through moderate risk stratification, stringent monitoring for high-risk pregnant women can be implemented, decreasing the incidence of adversities.

First-Trimester Uterine Artery Doppler for the Prediction of SGA at Birth: The Great Obstetrical Syndromes Study

OBJECTIVE

To estimate the role of first-trimester uterine artery pulsatility index (UtA-PI) for the prediction of small-for-gestational age (SGA).

METHODS

We conducted a prospective cohort study of nulliparous women with singleton pregnancy (Great Obstetrical Syndromes study). UtA-PI was performed at 11 + 0 to 13 + 6 weeks and was reported in multiple of median (MoM). SGA was defined as birth weight below the 10th percentile and stratified as term or preterm SGA. Receiver operating characteristic curves analyses with their area under the curve (AUC) were used to estimate the predictive values of UtA-PI, alone and UtA-PI combined with maternal characteristics. We computed the detection rate and false-positive rate (FPR) of the SOGC SGA screening guidelines in our population.

RESULTS

Of 4610 participants, SGA was identified in 486 pregnancies (10.3%), including 15 (0.3%) associated with preterm delivery. Compared with unaffected pregnancies, the mean log UtA-PI was significantly higher in term SGA and preterm SGA. The difference between preterm SGA and unaffected pregnancies remains significant after exclusion of SGA without preeclampsia. First-trimester UtA-PI was more predictive of preterm (AUC: 0.89) than term (AUC: 0.60) SGA (P < 0.01). Combined with maternal characteristics, UtA-PI could have predicted 64% of preterm and 20% of term SGA (10% FPR). The SOGC guidelines criteria for early screening of SGA had a detection rate of 21% for a FPR of 21%.

CONCLUSIONS

First-trimester UtA-PI can be used to predict SGA, but mainly preterm SGA. The current SOGC guidelines criteria for SGA screening are not efficient in nulliparous women.

First-Trimester Maternal Serum Levels of sFLT1, PGF and ADMA Predict Preeclampsia

Background

Placental growth factor (PGF), soluble fms-like tyrosine kinase 1 (sFLT1) and asymmetric dimethylarginine (ADMA) are involved in the pathogenesis of preeclampsia. Abnormal maternal sFLT1, PGF and ADMA levels are detectable weeks before the onset of preeclampsia.

Objective

To investigate sFLT1, PGF and ADMA in the first trimester of pregnancy as predictors of preeclampsia.

Methods

In this prospective nested case-control study, 740 pregnant women enrolled at 12–16 weeks of gestation and followed up until 6 weeks after delivery at the Shanghai First Maternity and Infant Health Hospital of Tongji University between January 2010 and December 2012. Forty-four women developed preeclampsia. Urinary proteins were measured using 24-hour collection or dipsticks. sFLT1, PGF and ADMA were measured by ELISA in the first trimester. Pulsatility index (PI) was measured by Doppler ultrasound in the second trimester.

Results

First-trimester serum sFLT1 and ADMA levels of women who developed preeclampsia were significantly higher compared with women with normal pregnancies (sFLT1: 0.321±0.023 vs. 0.308±0.019 ng/ml, P = 0.001; ADMA: 0.86±0.16 vs. 0.68±0.20 μM, P<0.001). First-trimester serum PGF levels of women who developed preeclampsia were significantly lower than in women with normal pregnancies (115.72±32.55 vs. 217.30±74.48 pg/ml, P<0.001). Multiple logistic regression and receiver-operating characteristic curves identified first-trimester PGF and ADMA to be sensitive and selective predictors of preeclampsia (area under the curve [AUC]: 0.902), as well as second-trimester uterine artery pulse index (AUC: 0.836).

Conclusion

In the first trimester, maternal serum sFLT1, PGF and ADMA levels, as well as second-trimester uterine artery PI, could predict preeclampsia.

Development and validation of a risk factor scoring system for first-trimester prediction of preeclampsia

OBJECTIVE

The aim of this study was to develop a multiparameter risk-based scoring system for first-trimester prediction of preeclampsia and to validate this scoring system in our patient population.

STUDY DESIGN

Secondary analysis of a prospective cohort of 1,200 patients presenting for first-trimester aneuploidy screening. Maternal serum pregnancy-associated plasma protein A (PAPP-A) levels were measured and bilateral uterine artery (UA) Doppler studies performed. Using the first half of the study population, a prediction model for preeclampsia was created. Test performance characteristics were used to determine the optimal score for predicting preeclampsia. This model was then validated in the second half of the population.

RESULTS

Significant risk factors and their weighted scores derived from the prediction model were chronic hypertension (4), history of preeclampsia (3), pregestational diabetes (2), body mass index ≥ 30 kg/m(2) (2), bilateral UA notching (1), and PAPP-A MoM < 10 th percentile (1). The area under the curve (AUC) for the risk scoring system was 0.76 (95% confidence interval [CI], 0.69-0.83), and the optimal threshold for predicting preeclampsia was a total score of ≥ 6. This AUC did not differ significantly from the AUC observed in our validation cohort (AUC, 0.78 [95% CI, 0.69-0.86]; p = 0.75].

CONCLUSION

Our proposed risk factor scoring system demonstrates modest accuracy but excellent reproducibility for first-trimester prediction of preeclampsia.

Efficiency of first-trimester uterine artery Doppler, a-disintegrin and metalloprotease 12, pregnancy-associated plasma protein a, and maternal characteristics in the prediction of preeclampsia

OBJECTIVES

The purpose of this study was to estimate the efficiency of first-trimester uterine artery Doppler, A-disintegrin and metalloprotease 12 (ADAM12), pregnancy-associated plasma protein A (PAPP-A), and maternal characteristics in the prediction of preeclampsia.

METHODS

We conducted a prospective cohort study of patients presenting for first-trimester aneuploidy screening between 11 and 14 weeks' gestation. Maternal serum ADAM12 and PAPP-A levels were measured by an immunoassay, and mean uterine artery Doppler pulsatility indices were calculated. Outcomes of interest included preeclampsia, early preeclampsia (defined as requiring delivery at <34 weeks' gestation), and gestational hypertension. Logistic regression analysis was used to model the prediction of preeclampsia using ADAM12 multiples of the median (MoM), PAPP-A MoM, and uterine artery Doppler pulsatility index MoM, either individually or in combination. The sensitivity, specificity, and area under the receiver operating characteristic curves were used to compare the screening efficiency of the models using nonparametric U statistics.

RESULTS

Among 578 patients with complete outcome data, there were 54 cases of preeclampsia (9.3%) and 13 cases of early preeclampsia (2.2%). Median ADAM12 levels were significantly lower in patients who developed preeclampsia compared to those who did not (0.81 versus 1.01 MoM; P = .04). For a fixed false-positive rate of 10%, ADAM12, PAPP-A, and uterine artery Doppler parameters in combination with maternal characteristics identified 50%, 48%, and 52% of patients who developed preeclampsia, respectively. Combining these first-trimester parameters did not improve the predictive efficiency of the models.

CONCLUSIONS

First-trimester ADAM12, PAPP-A, and uterine artery Doppler characteristics are not sufficiently predictive of preeclampsia. Combinations of these parameters do not further improve their screening efficiency.

Hypertensive disorders of pregnancy: preventative-, immediate- and long-term management

The hypertensive disorders of pregnancy are common and continue to be significant contributors to maternal and perinatal mortality and morbidity, both globally and in the UK. This review aims to describe the recent developments in the understanding of the pathophysiology of the disease processes, potential strategies for identification of women at high risk, and current and future therapeutic strategies for the treatment and prevention of hypertension in pregnancy. Women who experience adverse pregnancy outcomes are also at increased risk of premature cardiovascular disease, and potential therapeutic strategies to minimize their risk profile are discussed.

First-trimester assessment of placenta function and the prediction of preeclampsia and intrauterine growth restriction

Preeclampsia and intrauterine growth restriction (IUGR) are major contributors to perinatal mortality and morbidity worldwide. Both are characterized by impaired trophoblastic invasion of the maternal spiral arteries and their conversion from narrow muscular vessels to wide non-muscular channels. Despite improvement in the understanding of the pathophysiology of these conditions, ability to accurately identify pregnant woman who will develop them is limited. This greatly impairs the development and testing of preventive interventions. While different measures of placental dysfunction have been associated with increased risk for adverse pregnancy outcomes, the ability of any single one to accurately predict these outcomes is poor. Developing predictive tests is further challenged by difficulty in the timing of the measurements, as both the structural and biochemical characteristics of the placenta change with increasing gestational age. The ideal screening test would accurately predict the development of adverse pregnancy outcomes early enough to provide a window for preventive interventions. Improvement in ultrasound technology provides potentially useful novel tools for evaluating placental structure, but measurements need to be standardized in order to be useful. Maternal serum analyte screening is a noninvasive test of placental biochemical function, but present serum marker alone is not sufficiently accurate to suggest its routine use in clinical practice. The use of first trimester biochemical markers in combination with uterine artery Doppler screening is promising as a potential screening tool. Prospective longitudinal studies using standardized methodology are necessary to further evaluate the choice of parameters and strategies of combination to achieve the best predictive models.

Predicting risks of preeclampsia and small for gestational age infant by uterine artery Doppler

OBJECTIVE

To assess the value of uterine artery Doppler as a screening test for preeclampsia and/or having a small-for-gestational-age (SGA) infant in healthy pregnant women.

METHODS

Color Doppler ultrasound was used to examine both uterine arteries in 400 healthy pregnant women at 24.8 +/- 2.0 (range, 22 to 28) weeks of gestation. The mean pulsatility index of both uterine arteries was calculated and the presence of an early diastolic notch in the waveform was noted.

RESULTS

Twenty-six (6.5%) of the 400 women developed preeclampsia and/or had an SGA infant. The optimal cutoff value for the mean pulsatility index in predicting preeclampsia and/or having an SGA infant was 0.857. When using a high mean pulsatility index and/or the presence of any early diastolic notch, the detection of preeclampsia and/or having SGA infant were a sensitivity of 76.9%, a specificity of 52.9%, a positive predictive value of 10.2%, and a negative predictive value of 97.1%, respectively.

CONCLUSION

Women with an abnormal uterine artery Doppler great a considerably higher risk for developing preeclampsia and/or having an SGA infant.

The significance of uterine notching in Doppler sonography in early pregnancy as a predictor for pathologic outcome of the pregnancy

INTRODUCTION

Doppler sonography of maternal vessels as a predictor for preeclampsia is an established screening method in the second trimester. Considering the first trimester its benefit has not been conclusively proven so far. Up to now the flow pattern of maternal vessels in the first trimester has only been insufficiently characterized and documented. Thus, there are only few pieces of information concerning the predictive value of the different kinds of flow patterns during the early pregnancy as regards the pathological and physiological outcome of the pregnancy. This survey aimed at evaluating the significance and the clinical importance of Doppler sonographical examinations of the Aa. uterinae during early pregnancy. It had to be analyzed whether various perfusions can be applied as a predictive value for the specific development during the pregnancy and whether therefore a risk group for pregnancy-associated hypertension can already be detected during the early pregnancy.

MATERIALS AND METHODS

A non-selected collective of 104 pregnant patients was examined with Doppler sonography and retrospectively divided into a standard collective and a high-risk collective. The standard collective contained 89 patients, who in the course of their pregnancy remained without any pathological findings. Fifteen patients, who were assigned to the high-risk collective, either developed a pregnancy-induced hypertension during their pregnancy or an intrauterine fetal growth retardation. The Doppler-sonographic examination of the Aa. uterinae was applied for the first time between the 6 and 8 weeks gestation (WG), then in the 9 WG, 10 WG, 11 WG, between the 12 and 14 WG, as well as between the 20 and 24 WG.

RESULTS

Contrary to published data, there can be traced a completely transformed flow pattern in the Aa. uterinae already during the first trimester to an increasing extent. This correlates with a positive outcome of the pregnancy. There is a definite association between pathological Doppler sonography in the first third of the pregnancy and the development of a uteroplacental insufficiency as well as a pregnancy-associated hypertension (SIH) in the further course of the pregnancy.

CONCLUSION

Doppler sonography is an approved method in order to become early attentive of a reduced uterine blood flow. Applying Doppler sonographic treatment of the maternal vessels, uteroplacental insufficiency can be traced at an early stage. Pregnancies, which might develop a pregnancy-associated hypertension (SIH) or a placental insufficiency, can be detected during the early pregnancy to decrease the morbidity rate and the mortality of premature newborns. Further studies in larger collectives are necessary to obtain adequate solid datasets and to further evaluate the clinical meaning and the significance concerning pathological maternal Doppler parameters.