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Borbolla Foster A, Haxton J, Bennett N, Hyett J, Park F. Redesigning antenatal care: Prospective use of an implementation framework to establish a population-based multidisciplinary first-trimester screening, assessment and prevention service. Aust N Z J Obstet Gynaecol 2024. [PMID: 38779915 DOI: 10.1111/ajo.13837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/30/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Australian rates of adverse obstetric outcomes have improved little despite guidelines recommending history-based screening and intervention. The first trimester provides a unique opportunity to predict and prevent complications, yet population-based screening has failed to be translated into broad clinical practice. AIMS This study aimed to redesign antenatal care within an Australian public healthcare centre to align with evidence-based maternity care, including population-based first-trimester screening with early initiation of preventative strategies in high-risk pregnancies. METHODS A five-phase action-process model, sharing key elements with implementation science theory, was used to explore barriers to change in antenatal care, co-design a novel service with consumers and establish a population-based antenatal pathway commencing with a multidisciplinary first-trimester screening, assessment and planning visit. RESULTS The case for change and associated barriers were defined from the perspective of antenatal care stakeholders. Key needs of each group were established, and solutions were created using co-design methodology, allowing the team to create a novel approach to antenatal care which directly addressed identified barriers. Implementation of the service was associated with a fall in the median gestation at first specialist maternity care provider visit from 20 to 13 weeks. CONCLUSIONS This study confirms the feasibility of establishing a comprehensive first-trimester screening program within a public Australian healthcare setting and highlights a co-design process which places individualised assessment at the forefront of antenatal care. This framework may be applicable to most public maternity settings in Australia, with expansion aimed at providing equity of care, including in rural and remote settings.
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Affiliation(s)
- Ailsa Borbolla Foster
- Department of Maternity and Gynaecology, John Hunter Hospital, New Lambton Hts, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Jennifer Haxton
- Department of Maternity and Gynaecology, John Hunter Hospital, New Lambton Hts, New South Wales, Australia
| | - Nicole Bennett
- Department of Maternity and Gynaecology, John Hunter Hospital, New Lambton Hts, New South Wales, Australia
| | - Jon Hyett
- Ingham Institute, Faculty of Medicine, Western Sydney University, Liverpool, New South Wales, Australia
- Department of Obstetrics and Gynaecology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Felicity Park
- Department of Maternity and Gynaecology, John Hunter Hospital, New Lambton Hts, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
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Hromadnikova I, Kotlabova K, Krofta L. First trimester prediction models for small-for- gestational age and fetal growth restricted fetuses without the presence of preeclampsia. Mol Cell Probes 2023; 72:101941. [PMID: 37951512 DOI: 10.1016/j.mcp.2023.101941] [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: 10/20/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
We established efficient first trimester prediction models for small-for-gestational age (SGA) and fetal growth restriction (FGR) without the presence of preeclampsia (PE) regardless of the gestational age of the onset of the disease [early FGR occurring before 32 gestational week or late FGR occurring after 32 gestational week]. The retrospective study was performed on singleton Caucasian pregnancies (n = 6440) during the period 11/2012-3/2020. Finally, 4469 out of 6440 pregnancies had complete medical records since they delivered in the Institute for the Care of Mother and Child, Prague, Czech Republic. The study included all cases diagnosed with SGA (n = 37) or FGR (n = 82) without PE, and 80 selected normal pregnancies. Four microRNAs (miR-1-3p, miR-20a-5p, miR-146a-5p, and miR-181a-5p) identified 75.68 % SGA cases at 10.0 % false positive rate (FPR). Eight microRNAs (miR-1-3p, miR-20a-5p, miR-20b-5p, miR-126-3p, miR-130b-3p, miR-146a-5p, miR-181a-5p, and miR-499a-5p) identified 83.80 % SGA cases at 10.0 % FPR. The prediction model for SGA based on microRNAs was further improved via implementation of maternal clinical characteristics [maternal age and BMI, an infertility treatment by assisted reproductive technology (ART), first trimester screening for PE and/or FGR and for spontaneous preterm, both by FMF algorithm]. Then 81.08 % and 89.19 % pregnancies developing SGA were identified at 10.0 % FPR in case of utilization of 4 microRNA and 8 microRNA biomarkers. Simplified prediction model for SGA based on limited number of maternal clinical characteristics (maternal age and BMI, an infertility treatment by ART, and 4 microRNAs) does not improve the detection rate of SGA (70.27 % SGA cases at 10.0 % FPR) when compared with prediction model for SGA based just on the expression profile of 4 or 8 microRNAs biomarkers. Seven microRNAs only (miR-16-5p, miR-20a-5p, miR-145-5p, miR-146a-5p, miR-181a-5p, miR-342-3p, and miR-574-3p) identified 42.68 % FGR cases at 10.0 % FPR (AUC 0.725). However, the combination of 10 microRNAs only (miR-16-5p, miR-20a-5p, miR-100-5p, miR-143-3p, miR-145-5p, miR-146a-5p, miR-181a-5p, miR-195-5p, miR-342-3p, and miR-574-3p) reached a higher discrimination power (AUC 0.774). It identified 40.24 % FGR cases at 10.0 % FPR. The prediction model for any subtype of FGR based on microRNAs was further improved via implementation of maternal clinical characteristics [maternal age and BMI, an infertility treatment by ART, the parity (nulliparity), the occurrence of SGA or FGR in previous gestation, and the occurrence of any autoimmune disorder, and the presence of chronic hypertension]. Then 64.63 % and 65.85 % pregnancies destinated to develop FGR were identified at 10.0 % FPR in case of utilization of 7 microRNA biomarkers or 10 microRNA biomarkers. When other clinical variables next to those ones mentioned above such as first trimester screening for PE and/or FGR and for spontaneous preterm, both by FMF algorithm, were added to the prediction model for FGR, the detection power was even increased to 74.39 % cases and 78.05 % cases at 10.0 % FPR.
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Affiliation(s)
- Ilona Hromadnikova
- Department of Molecular Biology and Cell Pathology, Third Faculty of Medicine, Charles University, Prague, 100 00, Czech Republic.
| | - Katerina Kotlabova
- Department of Molecular Biology and Cell Pathology, Third Faculty of Medicine, Charles University, Prague, 100 00, Czech Republic.
| | - Ladislav Krofta
- Institute for the Care of the Mother and Child, Third Faculty of Medicine, Charles University, Prague, 147 00, Czech Republic.
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Spencer R, Maksym K, Hecher K, Maršál K, Figueras F, Ambler G, Whitwell H, Nené NR, Sebire NJ, Hansson SR, Diemert A, Brodszki J, Gratacós E, Ginsberg Y, Weissbach T, Peebles DM, Zachary I, Marlow N, Huertas-Ceballos A, David AL. Maternal PlGF and umbilical Dopplers predict pregnancy outcomes at diagnosis of early-onset fetal growth restriction. J Clin Invest 2023; 133:e169199. [PMID: 37712421 PMCID: PMC10503803 DOI: 10.1172/jci169199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/27/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUNDSevere, early-onset fetal growth restriction (FGR) causes significant fetal and neonatal mortality and morbidity. Predicting the outcome of affected pregnancies at the time of diagnosis is difficult, thus preventing accurate patient counseling. We investigated the use of maternal serum protein and ultrasound measurements at diagnosis to predict fetal or neonatal death and 3 secondary outcomes: fetal death or delivery at or before 28+0 weeks, development of abnormal umbilical artery (UmA) Doppler velocimetry, and slow fetal growth.METHODSWomen with singleton pregnancies (n = 142, estimated fetal weights [EFWs] below the third centile, less than 600 g, 20+0 to 26+6 weeks of gestation, no known chromosomal, genetic, or major structural abnormalities) were recruited from 4 European centers. Maternal serum from the discovery set (n = 63) was analyzed for 7 proteins linked to angiogenesis, 90 additional proteins associated with cardiovascular disease, and 5 proteins identified through pooled liquid chromatography and tandem mass spectrometry. Patient and clinician stakeholder priorities were used to select models tested in the validation set (n = 60), with final models calculated from combined data.RESULTSThe most discriminative model for fetal or neonatal death included the EFW z score (Hadlock 3 formula/Marsal chart), gestational age, and UmA Doppler category (AUC, 0.91; 95% CI, 0.86-0.97) but was less well calibrated than the model containing only the EFW z score (Hadlock 3/Marsal). The most discriminative model for fetal death or delivery at or before 28+0 weeks included maternal serum placental growth factor (PlGF) concentration and UmA Doppler category (AUC, 0.89; 95% CI, 0.83-0.94).CONCLUSIONUltrasound measurements and maternal serum PlGF concentration at diagnosis of severe, early-onset FGR predicted pregnancy outcomes of importance to patients and clinicians.TRIAL REGISTRATIONClinicalTrials.gov NCT02097667.FUNDINGThe European Union, Rosetrees Trust, Mitchell Charitable Trust.
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Affiliation(s)
- Rebecca Spencer
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Kasia Maksym
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karel Maršál
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Francesc Figueras
- Institut D’Investigacions Biomèdiques August Pi í Sunyer, University of Barcelona, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Barcelona, Spain
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - Harry Whitwell
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
- National Phenome Centre and Imperial Clinical Phenotyping Centre, Department of Metabolism, Digestion and Reproduction and
- Section of Bioanalytical Chemistry, Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Nuno Rocha Nené
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | - Neil J. Sebire
- Population, Policy and Practice Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Stefan R. Hansson
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Anke Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jana Brodszki
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Eduard Gratacós
- Institut D’Investigacions Biomèdiques August Pi í Sunyer, University of Barcelona, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Barcelona, Spain
| | - Yuval Ginsberg
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
- Department of Obstetrics and Gynecology, Rambam Medical Centre, Haifa, Israel
| | - Tal Weissbach
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
- Department of Obstetrics and Gynecology, Sheba Medical Center Tel Hashomer, Tel Aviv, Israel
| | - Donald M. Peebles
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | - Ian Zachary
- Division of Medicine, Faculty of Medical Sciences, University College London, United Kingdom
| | - Neil Marlow
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | - Angela Huertas-Ceballos
- Neonatal Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Anna L. David
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
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Uriel M, Romero Infante XC, Rincón Franco S, Ibáñez Pinilla EA, Rojas NA. Higher PAPP-A Values in Pregnant Women Complicated with Preeclampsia Than with Gestational Hypertension. Reprod Sci 2023:10.1007/s43032-023-01176-1. [PMID: 36917422 DOI: 10.1007/s43032-023-01176-1] [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: 02/21/2022] [Accepted: 01/20/2023] [Indexed: 03/15/2023]
Abstract
The purpose of this study is to compare the levels of maternal serum pregnancy-associated plasma protein-A at the first trimester in pregnancies complicated by impaired placental diseases, such as preeclampsia (PE), intrauterine fetal growth restriction (IUGR), and gestational hypertension (GH), with those in pregnancies without the development of any of these outcomes to expand the knowledge of how this protein behaves in the different impaired placental diseases. This current work is an observational study based on a prospective cohort. Pregnancy-associated plasma protein-A was measured in 422 patients who had completed maternal-perinatal outcomes. Comparisons of pregnancy characteristics and the biomarker between outcome groups (PE, IUGR, gestational hypertension, and not impaired placental outcomes) were analyzed. PAPP-A MoM in the IUGR (0.8 IQR: 0.6-0.9) and GH groups (0.5 IQR: 0.3-1.4) compared to the PE group (1.06 IQR: 0.66-1.52) was significantly lower (p < 0.005). Pregnant women who developed early-onset PE (1.11 IQR 1.08-1.18) presented significant differences with the IUGR group (0.83 IQR: 0.59-0.98; p = 0.002) and those who developed preterm-PE (1.19 IQR: 0.66-1.58; p = 0.045). The results demonstrate that the levels of PAPP-A at first trimester in the sample of women who developed PE, and specially term-PE, were higher than those in women who developed GH or IUGR. The GH group had the lowest PAPP-A values in this sample of pregnant women. Research in a population with a high prevalence of preeclampsia is still lacking and deserves more extended studies to define if these patients could have different rates of PAPP-A.
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Affiliation(s)
- Montserrat Uriel
- El Bosque Research Group of Maternal Fetal Medicine and Gynecology, Universidad El Bosque, Bogotá, Colombia.
- Ecodiagnóstico El Bosque S.A.S., Bogotá, Colombia.
- Los Cobos Medical Center, Bogotá, Colombia.
| | - Ximena Carolina Romero Infante
- El Bosque Research Group of Maternal Fetal Medicine and Gynecology, Universidad El Bosque, Bogotá, Colombia
- Ecodiagnóstico El Bosque S.A.S., Bogotá, Colombia
- Los Cobos Medical Center, Bogotá, Colombia
| | - Sara Rincón Franco
- El Bosque Research Group of Maternal Fetal Medicine and Gynecology, Universidad El Bosque, Bogotá, Colombia
- Ecodiagnóstico El Bosque S.A.S., Bogotá, Colombia
| | | | - Nydia Alexandra Rojas
- El Bosque Research Group of Maternal Fetal Medicine and Gynecology, Universidad El Bosque, Bogotá, Colombia
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Hromadnikova I, Kotlabova K, Krofta L. First-Trimester Screening for Fetal Growth Restriction and Small-for-Gestational-Age Pregnancies without Preeclampsia Using Cardiovascular Disease-Associated MicroRNA Biomarkers. Biomedicines 2022; 10:biomedicines10030718. [PMID: 35327520 PMCID: PMC8945808 DOI: 10.3390/biomedicines10030718] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 02/06/2023] Open
Abstract
The goal of the study was to determine the early diagnostical potential of cardiovascular disease-associated microRNAs for prediction of small-for-gestational-age (SGA) and fetal growth restriction (FGR) without preeclampsia (PE). The whole peripheral venous blood samples were collected within 10 to 13 weeks of gestation from singleton Caucasian pregnancies within the period November 2012 to March 2020. The case-control retrospective study, nested in a cohort, involved all pregnancies diagnosed with SGA (n = 37) or FGR (n = 82) without PE and 80 appropriate-for-gestational age (AGA) pregnancies selected with regard to equality of sample storage time. Gene expression of 29 cardiovascular disease-associated microRNAs was assessed using real-time RT-PCR. Upregulation of miR-16-5p, miR-20a-5p, miR-146a-5p, miR-155-5p, miR-181a-5p, and miR-195-5p was observed in SGA or FGR pregnancies at 10.0% false positive rate (FPR). Upregulation of miR-1-3p, miR-20b-5p, miR-126-3p, miR-130b-3p, and miR-499a-5p was observed in SGA pregnancies only at 10.0% FPR. Upregulation of miR-145-5p, miR-342-3p, and miR-574-3p was detected in FGR pregnancies at 10.0% FPR. The combination of four microRNA biomarkers (miR-1-3p, miR-20a-5p, miR-146a-5p, and miR-181a-5p) was able to identify 75.68% SGA pregnancies at 10.0% FPR in early stages of gestation. The detection rate of SGA pregnancies without PE increased 4.67-fold (75.68% vs. 16.22%) when compared with the routine first-trimester screening for PE and/or FGR based on the criteria of the Fetal Medicine Foundation. The combination of seven microRNA biomarkers (miR-16-5p, miR-20a-5p, miR-145-5p, miR-146a-5p, miR-181a-5p, miR-342-3p, and miR-574-3p) was able to identify 42.68% FGR pregnancies at 10.0% FPR in early stages of gestation. The detection rate of FGR pregnancies without PE increased 1.52-fold (42.68% vs. 28.05%) when compared with the routine first-trimester screening for PE and/or FGR based on the criteria of the Fetal Medicine Foundation. Cardiovascular disease-associated microRNAs represent promising early biomarkers with very suitable predictive potential for SGA or FGR without PE to be implemented into the routine screening programs.
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Affiliation(s)
- Ilona Hromadnikova
- Department of Molecular Biology and Cell Pathology, Third Faculty of Medicine, Charles University, 100 00 Prague, Czech Republic;
- Correspondence: ; Tel.: +420-296-511-336
| | - Katerina Kotlabova
- Department of Molecular Biology and Cell Pathology, Third Faculty of Medicine, Charles University, 100 00 Prague, Czech Republic;
| | - Ladislav Krofta
- Institute for the Care of the Mother and Child, Third Faculty of Medicine, Charles University, 147 00 Prague, Czech Republic;
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