Proteinuria in predicting adverse outcomes in women with severe features of pre-eclampsia from a developing country: A prospective cohort study

OBJECTIVE

To study the adverse maternal and perinatal outcomes in women with severe pre-eclampsia (SPE) among different ranges of proteinuria.

METHODS

This prospective cohort study was conducted in Jawaharlal Institute of Postgraduate Medical Education and Research, India. After obtaining informed written consent, the 202 singleton women fulfilling the criteria of severe features of pre-eclampsia were stratified based on the value of urine protein-creatinine ratio (UPCR) as mild, moderate, severe, and massive proteinuria during pregnancy. Clinical outcomes were assessed and patients were followed up until 12 weeks postpartum to identify persistent proteinuria and hypertension.

RESULTS

Of the 202 women with SPE, adverse maternal outcomes were seen in 34.65% (n = 70) and adverse perinatal outcomes in 75.74% (n = 153). The demographic and clinical factors were similar among women with increasing severity of proteinuria, except for mean systolic blood pressure, serum creatinine and total serum protein. UPCR was found to have a significant correlation with composite adverse perinatal outcome (P < 0.001) and individual outcomes of neonatal intensive care unit admission for >48 h (P = 0.01) and neonatal sepsis (P = 0.02) but not adverse maternal outcomes (P = 0.201). The optimum UPCR cutoff for adverse perinatal outcomes was 1.6 (sensitivity, 73.2%; specificity, 52.7%). In addition, 14.85% of the women had a persistently elevated UPCR and 3.96% had hypertension at 3 months postpartum.

CONCLUSION

In women with SPE, severe and massive proteinuria were related to composite adverse perinatal outcome but not composite adverse maternal outcome. Moreover, antenatal 24-h proteinuria was significantly associated with persistent proteinuria. Significant proteinuria in women with SPE poses a risk for chronic renal dysfunction, requiring follow-up.

Expression and significance of silent information regulator two homolog 1 in the placenta and plasma of patients with pre-eclampsia-a meta-analysis

OBJECTIVE

This study aimed to collect, organize, and conduct a meta-analysis of the literature on the expression of silent information regulator two homolog 1 (SIRT1) in the placental tissue and plasma of patients with pre-eclampsia.

METHODS

The enrolled patients were divided into two groups: the pre-eclampsia group and the healthy group. This study summarized and analyzed the demographic characteristics of the two groups, including pregnancy age, gestational weeks, parity, gravidity, blood pressure, Body Mass Index, newborn weight, placental weight, and SIRT1 expression in placental tissue and maternal plasma.

RESULTS

Eleven studies were included in this research, with 586 cases in the pre-eclampsia group and 479 cases in the control group. Three research studies are reporting immunohistochemistry tests, among which the pre-eclampsia group had a positivity rate of 30.24% (62/205), while the control group had 58.02% (76/131); the two groups have a significant difference (p < 0.05). Two research studies reported the results of ELISA tests, with 107 cases in the pre-eclampsia group and 125 cases in the control group. A comparison of the SIRT1 test results showed a statistically significant difference between the two groups (p < 0.05). Pre-eclampsia group patients had lower gestational weeks, newborn birth weight, and placental weight compared to the healthy control group (all p < 0.05). However, systolic and diastolic blood pressures were higher in the pre-eclampsia group than in the control group (p < 0.05).

CONCLUSION

SIRT1 expression is downregulated in pre-eclampsia patients' plasma and placental tissue. Further research is needed to validate this conclusion.

WITHDRAWN: Prevalence of Non-Proteinuric Preeclampsia at Mansoura University Hospitals

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Ophthalmic artery Doppler in the complementary diagnosis of preeclampsia: a systematic review and meta-analysis

OBJECTIVE

To evaluate the accuracy of different parameters of the ophthalmic artery Doppler (OAD) in the complementary diagnosis of preeclampsia (PE).

METHODS

This meta-analysis adhered to the PRISMA guidelines. To investigate the mean difference in OAD values, peak systolic velocity (PSV), end-diastolic velocity (EDV), second systolic velocity peak (P2), resistance index (RI), pulsatility index (PI), and peak ratio (PR), between PE cases (overall and according to severity) and controls, random-effects meta-analyses were conducted for each Doppler parameter, with overall PE and mild and severe PE subgroups. Diagnostic performance and heterogeneity were evaluated with summary receiver operating characteristic (sROC) curves and 95% confidence intervals obtained with bivariate models.

RESULTS

Eight studies stratified the results into mild and severe or late and early PE, involving 1,425 pregnant women. PR and P2 had better diagnostic performance than the other indexes, with the PR of AUsROC at 0.885, the sensitivity of 84%, and specificity of 92%, with a low false-positive rate of 0.08 and the P2 with AUsROC of 0.926, the sensitivity of 85% and specificity of 88%. RI, PI, and EDV showed good performance and consistency across studies but lower AUsROC values of 0.833, 0.794, and 0.772, respectively.

CONCLUSION

Ophthalmic artery Doppler is a complementary tool with good performance for the diagnosis of overall and severe preeclampsia, with high and best sensitivity and specificity when using PR and P2 parameters.

The association between protein levels in 24-hour urine samples and maternal and neonatal outcomes of pregnant women with preeclampsia

Objective

Hypertensive diseases of pregnancy are one of the leading causes of maternal and perinatal mortality worldwide. The aim of this study was to evaluate the association between protein levels in 24-hour urine samples and maternal and perinatal outcomes in preeclamptic patients.

Material and Methods

This retrospective cohort study was conducted with pregnant women who were diagnosed with preeclampsia (PE) and delivered in our clinic between 2010 and 2018. Patients were divided into those with a proteinuria value below 300 mg/24 h (non-proteinuria), proteinuria value between 300-2000 mg/24 h (mild proteinuria), proteinuria value between 2000-5000 mg/24 h (severe proteinuria) and proteinuria value >5000 mg/24 h (massive proteinuria) and were compared in terms of maternal and perinatal outcomes. Demographic characteristics (age, body mass index in kg/m2, gravidity), PE-related clinical symptoms (epigastric pain, neurological and respiratory symptoms), laboratory findings (24 h protein level, lactate dehydrogenase, aspartate aminotransferase, platelet count and creatine levels) were recorded in all patients.

Results

A total of 1,379 patients meeting the study criteria were included. There were 315 (23%) patients in the non-proteinuria group, 704 (51%) in the mild proteinuria group, 234 (17%) patients in the severe group and 126 (9%) patients in the massive proteinuria group. The massive proteinuria group was found to have the highest rates of maternal and prenatal complications. The Apgar score, umbilical cord pH value, birth weight, gestational week at delivery, intrauterine growth restriction and intrauterine fetal death were significantly higher in the massive proteinuria group.

Conclusion

Our data showed that the degree of proteinuria appears to be associated with maternal, fetal and neonatal outcomes among women diagnosed with PE. Women with proteinuria of >5000 mg/24 hours had notably poorer natal outcomes.

Diagnosis of proteinuria using a random urine protein-creatinine ratio and its correlation with adverse outcomes in pregnancy with preeclampsia characterized by renal damage

Based on a limited number of studies, a random urine protein‐creatinine ratio (uPCR) value of ≥ 0.3 indicates abnormal proteinuria in preeclampsia with renal damage. However, current guidelines do not recommend a reasonable diagnostic threshold of uPCR for severe preeclampsia with renal damage. Furthermore, the correlation between the uPCR value and clinical adverse outcomes remains poorly understood. The aim of the present study was to evaluate the value of uPCR in the diagnosis of significant proteinuria and to assess its correlation with adverse pregnancy outcomes in preeclampsia characterized by renal damage. In all, 1837 women were enrolled in this retrospective cohort study. Eventually, 961 women were enrolled under the exclusion criteria. First, the authors found that uPCR and 24‐hour proteinuria showed a significant association (r = 0.901). The optimal threshold of uPCR for diagnosing preeclampsia was 0.295, and for diagnosing severe preeclampsia the cut‐off was 0.625. Meanwhile, the adjusted odds ratio per 1 unit increase in ln (uPCR) was 1.679 (95% confidence interval [CI]:1.142–2.469) for severe adverse perinatal outcomes; 1.456 (95% CI: 1.242–1.705) for small for gestational age; 1.380 (95% CI: 1.051–1.811) for severe small for gestational age; 1.672 (95% CI: 1.210–2.310) for very early preterm birth; 1.989 (95% CI 1.726–2.293) for severe hypertension; and 2.279 (95% CI 1.906–2.724) for preterm birth. This study indicated that there was a significant and positive correlation between uPCR and 24‐hour urine protein. For neonatal and maternal adverse outcomes, uPCR is an independent predictor of prognosis.

Substantial decrease in preeclampsia prevalence and risk over two decades: A population-based study of 1,153,227 deliveries in Norway

OBJECTIVES

Analyze secular trends of preeclampsia in Norway based on risk factors.

STUDY DESIGN

Population-based cohort study of 1,153,227 women using data from Medical Birth Registry of Norway from 1999 to 2018. Aggregated data from Norwegian Prescription Database from 2004 to 2018 were used. Main exposure variable was time period. Descriptive statistics identified the prevalence of preeclampsia, labor induction and aspirin use. Multiple logistic regression analysis was performed to estimate the risk of preeclampsia during the time periods.

MAIN OUTCOME MEASURES

Preeclampsia.

RESULTS

Overall preeclampsia prevalence decreased from 4.3% in 1999-2002 to 2.7% in 2015-2018. A reduction was observed in all subgroups of women with known risk factors (age, nulliparity, diabetes, chronic hypertension, assisted reproduction, twin pregnancy). Adjusted risk of preeclampsia was reduced by 44% from 1999-2002 to 2015-2018 (aOR = 0.56, 95%CI 0.54, 0.58), while the net prevalence of gestational hypertension remained stable over the study period. Labor induction increased 104%. Aspirin prescriptions increased among fertile women in the general Norwegian population.

CONCLUSIONS

Preeclampsia prevalence and risk were reduced regardless of risk factors and despite an increased proportion of high-risk parturients (advanced age, lower parity, use of assisted reproduction). A corresponding increase in aspirin prescriptions among fertile women and an overall increase in labor inductions were also observed, suggesting that clinical interventions may partly explain the observed reduction in preeclampsia prevalence. Lower average blood pressure and improved health in the population may also explain some of the reduction.

Proteinuria during pregnancy: definition, pathophysiology, methodology, and clinical significance

Qualitative and quantitative measurement of urine protein excretion is one of the most common tests performed during pregnancy. For more than 100 years, proteinuria was necessary for the diagnosis of preeclampsia, but recent guidelines recommend that proteinuria is sufficient but not necessary for the diagnosis. Still, in clinical practice, most patients with gestational hypertension will be diagnosed as having preeclampsia based on the presence of proteinuria. Although the reference standard for measuring urinary protein excretion is a 24-hour urine collection, spot urine protein-to-creatinine ratio is a reasonable "rule-out" test for proteinuria. Urine dipstick screening for proteinuria does not provide any clinical benefit and should not be used to diagnose proteinuria. The classic cutoff cited to define proteinuria during pregnancy is a value of >300 mg/24 hours or a urine protein-to-creatinine ratio of at least 0.3. Using this cutoff, the rate of isolated proteinuria in pregnancy may reach 8%, whereas preeclampsia occurs among 3% to 8% of pregnancies. Although this threshold is widely accepted, its origin is not based on evidence on adverse pregnancy outcomes but rather on expert opinion and results of small studies. After reviewing the available data, the most important factor that influences maternal and neonatal outcome is the severity of blood pressures and presence of end organ damage, rather than the excess protein excretion. Because the management of gestational hypertension and preeclampsia without severe features is almost identical in frequency of surveillance and timing of delivery, the separation into 2 disorders is unnecessary. If the management of women with gestational hypertension with a positive assessment of proteinuria will not change, we believe that urine assessment for proteinuria is unnecessary in women who develop new-onset blood pressure at or after 20 weeks' gestation. Furthermore, we do not recommend repeated measurement of proteinuria for women with preeclampsia, the amount of proteinuria does not seem to be related to poor maternal and neonatal outcomes, and monitoring proteinuria may lead to unindicated preterm deliveries and related neonatal complications. Our current diagnosis of preeclampsia in women with chronic kidney disease may be based on a change in protein excretion, a baseline protein excretion evaluation is critical in certain conditions such as chronic hypertension, diabetes, and autoimmune or other renal disorders. The current definition of superimposed preeclampsia possesses a diagnostic dilemma, and it is unclear whether a change in the baseline proteinuria reflects another systemic disease such as preeclampsia or whether women with chronic disease such as chronic hypertension or diabetes will experience a different "normal" pattern of protein excretion during pregnancy. Finally, limited data are available regarding angiogenic and other biomarkers in women with chronic kidney disease as a potential aid in distinguishing the worsening of baseline chronic kidney disease and chronic hypertension from superimposed preeclampsia.

Preeclampsia and eclampsia: the conceptual evolution of a syndrome

Preeclampsia, one of the most enigmatic complications of pregnancy, is considered a pregnancy-specific disorder caused by the placenta and cured only by delivery. This article traces the condition from its origins-once thought to be a disease of the central nervous system, recognized by the occurrence of seizures (ie, eclampsia)-to the present time when preeclampsia is conceptualized primarily as a vascular disorder. We review the epidemiologic data that led to the recommendation to use diastolic hypertension and proteinuria as diagnostic criteria, as their combined presence was associated with an increased risk of fetal death and the birth of small-for-gestational-age neonates. However, preeclampsia is a multisystemic disorder with protean manifestations, and the condition can be present even in the absence of hypertension and proteinuria. Toxins gaining access to the maternal circulation have been proposed to mediate the clinical manifestations-hence, the term "toxemia of pregnancy," which was used for several decades. The search for putative toxins has challenged investigators for more than a century, and a growing body of evidence suggests that products of an ischemic or a stressed placenta are responsible for the vascular changes that characterize this syndrome. The discovery that the placenta can produce antiangiogenic factors, which regulate endothelial cell function and induce intravascular inflammation, has been a major step forward in the understanding of preeclampsia. We view the release of antiangiogenic factors by the placenta as an adaptive response to improve uterine perfusion by modulating endothelial function and maternal cardiovascular performance. However, this homeostatic response can become maladaptive and lead to damage of target organs during pregnancy or the postpartum period. Early-onset preeclampsia has many features in common with atherosclerosis, whereas late-onset preeclampsia seems to result from a mismatch of fetal demands and maternal supply, that is, a metabolic crisis. Preeclampsia, as it is understood today, is essentially vascular dysfunction unmasked or caused by pregnancy. A subset of patients diagnosed with preeclampsia are at greater risk of the subsequent development of hypertension, ischemic heart disease, heart failure, vascular dementia, and end-stage renal disease. However, these adverse events may be the result of a preexisting vascular pathologic process; it is not known if the occurrence of preeclampsia increases the baseline risk. Therefore, the understanding, prediction, prevention, and treatment of preeclampsia are healthcare priorities.

The diagnostic value of angiogenic and antiangiogenic factors in differential diagnosis of preeclampsia

The definition of preeclampsia is changing. However, with the addition of organ symptoms to the presence of hypertension in pregnancy instead of relying only on proteinuria, a more precise detection of women at risk of preeclampsia-associated adverse events has not been achieved. Instead, under the new definitions of the American College of Obstetricians and Gynecologists and of the International Society for the Study of Hypertension in Pregnancy, more women are classified as preeclamptic, with a tendency to milder disease. Furthermore, angiogenic and antiangiogenic factors have emerged as essential tools for predicting and diagnosing preeclampsia at high accuracies. Next to being rooted in the pathophysiology of the disease, they have been proven to be reliable tools for predicting and diagnosing the disease. In addition, 2 cutoffs have been evaluated for the clinical setting. As shown in the Prediction of Short-Term Outcome in Pregnant Women With Suspected Preeclampsia Study, at the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio cutoff of 38, a preeclampsia can be ruled out for 1 week with a negative predictive value of 99.3% (95% confidence interval, 97.9-99.9) and ruled in with a positive predictive value of 36.7% (95% confidence interval, 28.4-45.7). The diagnostic cutoff of 85 has been shown to accurately identify women with preeclampsia, with a sensitivity of up to 88% and a specificity of 99.5%. In this review, we highlight the central role of angiogenic and antiangiogenic factors in the differential diagnosis of women presenting at high risk of the disease, such as patients with chronic hypertension or chronic kidney disease. We will focus on their ability to predict preeclampsia-associated adverse fetal and maternal outcomes. This is only possible when critically reviewing the evolution of the definition of "preeclampsia." We show how changes in this definition shape our clinical picture of the condition and how angiogenic and antiangiogenic biomarkers might be included to better identify women destined to develop preeclampsia-related adverse outcomes.

Performance of ophthalmic artery Doppler velocimetry in the complementary diagnosis of preeclampsia

OBJECTIVES

To calculate the accuracy (A) and establish the best cutoff value for ophthalmic artery (OA) Doppler velocimetry indexes in patients diagnosed with preeclampsia (PE), compared with healthy pregnant women.

METHODS

This prospective experimental study enrolled 268 women: 133 with PE and 135 healthy pregnant women. All patients were evaluated by OA Doppler sonography, bilaterally, to assess their pulsatility index (PI), resistance index (RI), peak systolic velocity (PVS), second peak systolic velocity (P2), end-diastolic velocity (EDV), and peak ratio (PR). Means were compared using Student's T-test. Receiver Operating Characteristics (ROC) curve was used to establish the cutoff value and estimate the sensitivity (S), specificity (Sp), accuracy (A) of all variables, and a significance of 95% was adopted.

RESULTS

ROC curve analysis showed that P2 and PR were superior to the other parameters for PE diagnosis. We tested two cutoff values: (1) using PR ≥0.70, obtained A: 88.72%, S: 81.95%, and Sp: 95.48% and (2) using PR ≥0.75, and A: 86.24%, S: 74.43%, and Sp: 99.24%. By adopting P2 ≥ 21.5 cm/s, we obtained A: 87.59%, S: 84.96%, and Sp: 90.22% and when the cutoff point was P2 ≥ 22 cm/s, there was a slight decrease in A to 86.46% and S to 81.20%, with Sp: 91.89.3%.

CONCLUSION

Ophthalmic artery Doppler demonstrated to be an effective and high-performance imaging method for the diagnosis of PE and the indexes P2 and PR demonstrated superior accuracy to the other Doppler parameters assessed. Higher performance occurred when the cutoff values with greater specificity were adopted, PR ≥ 0.75 and P2 ≥ 22 cm/s, considering that the proposed OA Doppler is to be a complementary method for preeclampsia.

Changes in rate of preterm birth and adverse pregnancy outcomes attributed to preeclampsia after introduction of a refined definition of preeclampsia: A population-based study

INTRODUCTION

Since 2013, various guidelines for hypertension in pregnancy have been refined, no longer requiring proteinuria as a requisite criterion for preeclampsia. We aimed to evaluate the impact of the new definition on preterm birth (PTB) and adverse pregnancy outcomes.

MATERIAL AND METHODS

Women delivering in Ontario between April 2012 and November 2016 were included. Delivery <24+0/7 weeks, major fetal anomalies or preexisting renal disease were excluded. The primary outcome was livebirth <37, <34 or <32 weeks. Rates, adjusted rate ratios (aRR) and ratio of the rate ratio (RRR) were used to compare outcomes in the 2 years after the new Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline (December 2014-November 2016; period 2) vs the 2 years before (April 2012-March 2014; period 1), among women with and without preeclampsia.

RESULTS

In all, 268 543 and 267 964 births in periods 1 & 2, respectively, were included. Respective preeclampsia rates increased significantly from 3.9% to 4.4% (p < 0.001), with no change in maternal morbidity rates. In preeclamptic women, respective rates of PTB <37 weeks were 21.0% and 20.7% (aRR 1.01, 95% confidence interval [CI] 1.00-1.02), with significant aRR for PTB <34 (0.86, 95% CI 0.77-0.96) and <32 weeks (0.79, 95% CI 0.67-0.94). A similar aRR was observed in women without preeclampsia. In preeclamptic women, composite severe neonatal morbidity decreased after guideline change (aRR 0.95, 95% CI 0.91-0.99), a finding not observed in women without preeclampsia (RRR 0.95, 95% CI 0.91-0.99).

CONCLUSIONS

The new definition of preeclampsia was associated with increased disease rates, a modest reduction in adverse neonatal outcomes and no change in maternal outcomes.

Earlier onset of proteinuria or hypertension is a predictor of progression from gestational hypertension or gestational proteinuria to preeclampsia

Although gestational hypertension (GH) is a well-known disorder, gestational proteinuria (GP) has been far less emphasized. According to international criteria, hypertensive disorders of pregnancy include GH but not GP. Previous studies have not revealed the predictors of progression from GP to preeclampsia or those of progression from GH to preeclampsia. We aimed to determine both sets of predictors. A retrospective cohort study was conducted with singleton pregnant women who delivered at 22 gestational weeks or later. Preeclampsia was divided into three types: new onset of hypertension/proteinuria at 20 gestational weeks or later and additional new onset of other symptoms at < 7 days or at ≥ 7 days later. Of 94 women with preeclampsia, 20 exhibited proteinuria before preeclampsia, 14 experienced hypertension before preeclampsia, and 60 exhibited simultaneous new onset of both hypertension and proteinuria before preeclampsia; the outcomes of all types were similar. Of 34 women with presumptive GP, 58.8% developed preeclampsia; this proportion was significantly higher than that of 89 women with presumptive GH who developed preeclampsia (15.7%). According to multivariate logistic regression models, earlier onset of hypertension/proteinuria (before or at 34.7/33.9 gestational weeks) was a predicator for progression from presumptive GH/GP to preeclampsia (odds ratios: 1.21/1.21, P value: 0.0044/0.0477, respectively).

Use of the angiogenic biomarker profile to risk stratify patients with fetal growth restriction

BACKGROUND

Novel angiogenic biomarker profiles have demonstrated emerging evidence for predicting preeclampsia onset, severity, and adverse outcomes. Limited data exist in screening patients with fetal growth restriction for preeclampsia development using angiogenic biomarkers.

OBJECTIVE

The objective of this study was to risk stratify patients with fetal growth restriction using a soluble fms-like tyrosine kinase-1 to placental growth factor ratio. Previously published cutoff of 38 was used to predict preeclampsia development and severity as well as adverse maternal or neonatal outcomes within a 2-week time period.

STUDY DESIGN

This was a prospective observational cohort study performed in a single tertiary hospital. Patients with a singleton fetal growth restriction pregnancy between 24 and 37 weeks' gestation were evaluated using serial 2-week encounters from the time of enrollment to delivery. Pregnancies with proven genetic or infectious etiology of fetal growth restriction or congenital anomalies were excluded. Ultrasound growth and Doppler measurements were obtained at the start of every encounter with routine preeclampsia laboratory tests and blood pressure checks when clinically indicated. Maternal serum was collected for all serial encounters and measured for soluble fms-like tyrosine kinase-1 and placental growth factor after delivery in a double-blinded fashion. Maternal charts were reviewed for baseline demographic characteristics, pregnancy diagnoses and outcomes, and neonatal outcomes.

RESULTS

A total of 45 patients were enrolled for a total of 77 encounters, with the median (quartile 1, quartile 3) gestational age of the study enrolled at 31.43 (28.14-33.57) weeks. Patients were divided into low-risk (ratio of <38) and high-risk (ratio of ≥38) groups. Baseline characteristics of patients did not show any marked differences, including preeclampsia labs or ultrasound parameters, between the 2 groups. Systolic and diastolic blood pressures upon enrollment were statistically elevated when soluble fms-like tyrosine kinase-1 to placental growth factor ratio was ≥38 (P=.02 and P=.01, respectively). Compared to patients with a low ratio, patients with a high ratio had a greater proportion of preeclampsia diagnosis, higher rates of preterm delivery under 34 and 37 weeks gestation, smaller neonatal birthweight, and a shorter time to delivery from testing to delivery.

CONCLUSION

Among patients with fetal growth restriction, the soluble fms-like tyrosine kinase-1 to placental growth factor ratio may serve as a potential biomarker for identifying at risk patients for developing preeclampsia and subsequently preterm delivery.

Fetal growth restriction as a diagnostic criterion for preeclampsia

OBJECTIVES

Currently, no unified set of criteria to classify preeclampsia (PE) exists. Further, no consensus has been reached whether fetal growth restriction (FGR) should be included in diagnostic criteria for PE. We examined the adequacy of including FGR in diagnostic criteria for PE.

STUDY DESIGN

Singleton pregnancy patients who developed PE before 34 weeks of gestation managed at a tertiary center between 2010 and 2016 were included. Patients were divided into two groups according to cause for PE diagnosis. In addition, those diagnosed with PE because of gestational hypertension (GH) and FGR were divided into two groups according to presence of proteinuria or organ dysfunction during the expectant management.

MAIN OUTCOME MEASURES

Pregnancy prolongation from PE diagnosis.

RESULTS

Of 69 PE patients, 18 (28.1%) were diagnosed as PE with GH and only FGR (F group). Pregnancy prolongation between PE diagnosis to delivery was longer in the F group than in PE cases with primary organ dysfunction (P group) (21 vs 10 days, P = 0.049). Of 18 patients in the F group, 12 (66.7%) subsequently had proteinuria or organ dysfunction (S group). The remaining 6 patients (33.3%) had no subsequent proteinuria or organ dysfunction (N group). There were no significant differences in prolongation of pregnancy from organ dysfunction onset to delivery between the S and P groups (10 vs 10 days, P = 0.36).

CONCLUSIONS

Organ dysfunction onset may reflect PE progression more accurately than FGR onset. Further investigations on whether to include FGR into the diagnostic criteria for PE are needed.

Impact of new definitions of pre-eclampsia on incidence and performance of first-trimester screening

OBJECTIVE

The traditional definition of pre-eclampsia (PE) is based on the development of hypertension and proteinuria. This has been revised recently to include cases without proteinuria but with evidence of renal, hepatic or hematological dysfunction. The aim of this study was to examine the impact of new definitions of PE on, first, the incidence and severity of the disease and, second, the performance of the competing-risks model for first-trimester assessment of risk for PE.

METHODS

This was a retrospective study of 66 964 singleton pregnancies that were classified as having PE, gestational hypertension (GH) or no PE or GH, according to the traditional criteria of the International Society for the Study of Hypertension in Pregnancy (ISSHP-old), which defines PE as the presence of both hypertension and proteinuria. We reviewed the records of pregnancies with GH, and those cases with high creatinine or liver enzymes or low platelet count were reclassified as having PE, according to the new criteria of ISSHP (ISSHP-new) and the new criteria of the American College of Obstetricians and Gynecologists (ACOG). The groups of PE according to the traditional and new criteria were compared for, first, gestational age at delivery, birth-weight percentile and incidence of a small-for-gestational-age (SGA) neonate with birth weight < 10^th percentile and perinatal death, and, second, the predictive performance for preterm PE of the competing-risks model based on the combination of maternal risk factors, uterine artery pulsatility index, mean arterial pressure and serum placental growth factor at 11-13 weeks' gestation (triple test).

RESULTS

According to ISSHP-old, 1870 (2.8%) cases had PE, 2182 (3.3%) had GH and 62 912 (94.0%) had no PE or GH. The incidence of PE according to ACOG was 3.0% (2029/66 964) and ISSHP-new was 3.4% (2301/66 964). Median gestational age at delivery in the extra cases of PE according to ACOG (difference, 1.3 weeks; 95% CI, 0.71-1.71 weeks) and in the extra cases of PE according to ISSHP-new (difference, 1.5 weeks; 95% CI, 1.29-1.71 weeks) was higher than in cases with PE according to ISSHP-old (38.4 weeks). The incidence of a SGA neonate in the extra cases of PE according to ACOG (relative risk, 0.57; 95% CI, 0.42-0.79) and in the extra cases of PE according to ISSHP-new (relative risk, 0.52; 95% CI, 0.42-0.65) was lower than in the cases of PE according to ISSHP-old (33.64%). In first-trimester screening for preterm PE by the triple test, the detection rate, at a 10% false-positive rate, was 75.9% (95% CI, 70.8-80.6%) for ISSHP-old, 74.3% (95% CI, 69.2-79.0%) for ACOG and 74.0% (95% CI, 68.9-78.6%) for ISSHP-new.

CONCLUSIONS

The new definitions of PE resulted in, first, an increase in pregnancies classified as having PE but the additional cases had milder disease, and, second, a non-significant decrease in the performance of first-trimester screening for PE. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.