Screening for pre-eclampsia with competing-risks model using placental growth factor measurement in blood samples collected before 11 weeks' gestation

OBJECTIVES

To describe the distributional properties and assess the performance of placental growth factor (PlGF) measured in blood samples collected before 11 weeks' gestation in the prediction of pre-eclampsia (PE).

METHODS

The study population consisted of pregnant women included in the Pre-eclampsia Screening in Denmark (PRESIDE) study with a PlGF measurement from the routine combined first-trimester screening (cFTS) blood sample collected at 8-14 weeks' gestation. PRESIDE was a prospective multicenter study investigating the predictive performance of the Fetal Medicine Foundation (FMF) first-trimester screening algorithm for PE in a Danish population. In the current study, serum concentration of PlGF in the cFTS blood samples was analyzed in batches between January and June 2021.

RESULTS

A total of 8386 pregnant women were included. The incidence of PE was 0.7% at < 37 weeks' gestation and 3.0% at ≥ 37 weeks. In blood samples collected at 10 weeks' gestation, PlGF multiples of the median (MoM) were significantly lower in pregnancies with preterm PE < 37 weeks compared to unaffected pregnancies. However, PlGF MoM did not differ significantly between pregnancies with PE and unaffected pregnancies in samples collected before 10 weeks' gestation.

CONCLUSIONS

The gestational-age range for PlGF sampling may be expanded from 11-14 to 10-14 weeks when assessing the risk for PE using the FMF first-trimester screening model. There is little evidence to support the use of PlGF in blood samples collected before 10 weeks' gestation. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Pre-eclampsia screening in Denmark (PRESIDE): national validation study

OBJECTIVES

To investigate the predictive performance of the Fetal Medicine Foundation (FMF) first-trimester screening algorithm for pre-eclampsia in a Danish population and compare screening performance with that of the current Danish strategy, which is based on maternal risk factors.

METHODS

This was a prospective study of women with a singleton pregnancy attending for their first-trimester ultrasound scan and screening for aneuploidies at six Danish university hospitals between May 2019 and December 2020. Prenatal data on maternal characteristics and medical history were recorded, and measurements of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum pregnancy-associated plasma protein-A (PAPP-A) and serum placental growth factor (PlGF) were collected without performing a risk assessment for pre-eclampsia. Information on acetylsalicylic acid use was recorded. After delivery, pregnancy outcome, including gestational age at delivery and pre-eclampsia diagnosis, was recorded. Pre-eclampsia risk assessment for each woman was calculated blinded to outcome using the FMF screening algorithm following adjustment to the Danish population. Detection rates (DRs) of the FMF algorithm were calculated for a fixed screen-positive rate (SPR) of 10% and for the SPR achieved in the current Danish screening.

RESULTS

A total of 8783 pregnant women were included, with a median age of 30.8 (interquartile range (IQR), 28.1-33.9) years. The majority were white (95%), naturally conceiving (90%), non-smokers (97%) and had no family history of pre-eclampsia (96%). The median body mass index was 23.4 (IQR, 21.2-26.6) kg/m2 . A complete risk assessment including maternal characteristics, MAP, UtA-PI, PlGF and PAPP-A was available for 8156 women (92.9%). In these women, UtA-PI was measured bilaterally with a median value of 1.58 (IQR, 1.27-1.94) and the median resting MAP of 80.5 (IQR, 76.1-85.4) mmHg in two consecutive measurements. Among these, 303 (3.7%) developed pre-eclampsia, including 55 (0.7%) cases of pre-eclampsia with delivery < 37 weeks of gestation and 16 (0.2%) cases of pre-eclampsia with delivery < 34 weeks. At a SPR of 10%, combined screening using the FMF algorithm based on maternal characteristics, MAP, UtA-PI, PlGF and PAPP-A had a DR of 77.4% (95% CI, 57.6-97.2%) for pre-eclampsia with delivery < 34 weeks, 66.8% (95% CI, 54.4-79.1%) for pre-eclampsia with delivery < 37 weeks and 44.1% (95% CI, 38.5-49.7%) for pre-eclampsia with delivery at any gestational age. The current Danish screening strategy using maternal risk factors detected 25.0% of women with pre-eclampsia with delivery < 34 weeks and 19.6% of women with pre-eclampsia with delivery < 37 weeks at a SPR of 3.4%. When applying the FMF algorithm including maternal characteristics, MAP, UtA-PI and PlGF at the fixed SPR of 3.4%, the DRs were 60.5% (95% CI, 36.9-84.1%) for PE with delivery < 34 weeks and 45.2% (95% CI, 32.0-58.5%) for PE with delivery < 37 weeks.

CONCLUSION

In this large Danish multicenter study, the FMF algorithm based on maternal characteristics, MAP, UtA-PI, PlGF and PAPP-A predicted 77.4% of cases with pre-eclampsia with delivery < 34 weeks and 66.8% of cases with pre-eclampsia with delivery < 37 weeks of gestation at a SPR of 10%, suggesting that the performance of the algorithm in a Danish cohort matches that in other populations. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Importance of patellofemoral and tibiofemoral cartilage lesions on trajectory of self-reported outcomes in patients at high risk of knee OA: 4-6 years follow-up of patients undergoing meniscal surgery

OBJECTIVE

We evaluated whether patient-reported outcome trajectories (i.e., changes over time) differed by intraoperative compartmental cartilage lesion pattern over 4-6 years following arthroscopic meniscal surgery.

METHODS

In this ancillary study of the Knee Arthroscopy Cohort Southern Denmark cohort, we intraoperatively categorized cartilage lesions as isolated patellofemoral, isolated tibiofemoral, or combined patellofemoral/tibiofemoral. Participants completed the Knee injury and Osteoarthritis Outcome Score (KOOS) pre-operatively, at 3 and 12 months, and at 4-6 years post-operatively and reported overall satisfaction at final follow-up. Our main outcome was KOOS₄ (grand mean of four subscale means). We evaluated whether KOOS₄ scores changed over time according to cartilage lesion patterns using adjusted mixed linear regression. We also estimated probability of treatment satisfaction using logistic regression.

RESULTS

Of 630 participants with complete cartilage scores, 280 (44%) were women, mean (standard deviation) age was 49 (13) years, and BMI was 27.3 (4.4) kg/m². KOOS₄ scores at baseline were slightly lower in all lesion groups compared to the no lesion group, yet only the combined group was statistically significantly lower. KOOS₄ trajectories were similar across cartilage lesion patterns, but by final follow-up, adjusted mean KOOS₄ scores were 6.8 (95% CI 2.2, 11.4) to 9.8 (1.1, 18.5) points lower in groups with cartilage lesions compared to the no lesion group. Probability of patient-reported satisfaction did not differ statistically by group.

CONCLUSIONS

Though KOOS₄ scores were slightly lower in groups with arthroscopically assessed cartilage lesions compared to the no lesion group, trajectories were similar across all groups.

Associations between comorbidities and immediate and one-year outcomes following supervised exercise therapy and patient education - A cohort study of 24,513 individuals with knee or hip osteoarthritis

OBJECTIVE

To investigate if comorbidities are associated with change in health outcomes following an 8-week exercise and education program in knee and hip osteoarthritis (OA).

METHODS

We included 24,513 individuals with knee or hip OA from the Good Life with osteoArthritis in Denmark (GLA:D®). GLA:D® consists of two patient education sessions and 12 supervised exercise sessions. Before the program, individuals self-reported having one or more of 11 common comorbidities. Physical function was assessed using the 40-m Fast-Paced Walk Test (FPWT, m/sec) before and immediately after the program. Pain intensity and health-related quality of life was self-reported before, immediately after, and at 12 months post-intervention using a visual analogue scale (VAS, 0-100) and the EQ-5D-5L index (-0.624 to 1.000), respectively. Associations of comorbidity combinations with change in outcomes immediately and at 12 months was estimated using mixed linear regression.

RESULTS

Individuals with OA improved on average 0.12 m/s (95%CI 0.12 to 0.13) in 40-m FPWT, -12.7 mm (95%CI -13.2 to -12.2) in VAS, and 0.039 (95%CI 0.036 to 0.041) in EQ-5D-5L from before to immediately after the intervention with minor additional improvements at 12 months. Despite that individuals with comorbidities had worse baseline scores in all outcomes than individuals without comorbidities, they had similar levels of improvement immediately and 12 months after the intervention.

CONCLUSION

Comorbidities are not associated with worse nor better health outcomes following an 8-week exercise and education program in individuals with OA, suggesting exercise as a viable treatment option for individuals with OA, irrespective of comorbidities.

Change in patient-reported outcomes in patients with and without mechanical symptoms undergoing arthroscopic meniscal surgery: A prospective cohort study

OBJECTIVE

Patients with degenerative or traumatic meniscal tears are at high risk of developing knee osteoarthritis. We investigated if younger (≤40 years) and older (>40 years) patients with preoperative mechanical symptoms (MS) improved more in patient-reported outcomes after meniscal surgery than those without MS.

DESIGN

Patients from Knee Arthroscopy Cohort Southern Denmark (KACS) undergoing arthroscopic surgery for a meniscal tear completed online questionnaires before surgery, and at 12 and 52 weeks follow-up. Questionnaires included self-reported presence of MS (i.e., sensation of catching and/or locking) and the Knee injury and Osteoarthritis Outcome Score (KOOS). We analyzed between-group differences in change in KOOS₄ from baseline to 52 weeks, using an adjusted mixed linear model.

RESULTS

150 younger patients (mean age 31 (SD 7), 67% men) and 491 older patients (mean age 54 (SD 9), 53% men) constituted the baseline cohorts. Patients with MS generally had worse self-reported outcomes before surgery. At 52 weeks follow-up, younger patients with preoperative MS had improved more in KOOS₄ scores than younger patients without preoperative MS (adjusted mean difference 10.5, 95% CI: 4.3, 16.6), but did not exceed the absolute postoperative KOOS₄ scores observed for those without MS. No difference in improvement was observed between older patients with or without MS (adjusted mean difference 0.7, 95% CI: -2.6, 3.9).

CONCLUSIONS

Younger patients (≤40 years) with preoperative MS experienced greater improvements after arthroscopic surgery compared to younger patients without MS. Our observational study result needs to be confirmed in randomized trials.

Choriocarcinoma presenting with cerebral metastases after full-term pregnancy

Choriocarcinoma is a rare malignancy in Scandinavia. We present a case of a young primigravida who experienced an uneventful pregnancy and gave birth to a healthy baby. Six days after delivery she underwent neurosurgery for intracranial hemorrhage. Pathological examination of the evacuated hematoma revealed metastatic choriocarcinoma. Further work-up exposed additional metastases in the lungs and liver. The initial serum level of human chorionic gonadotropin (beta-HCG) was 350,000 IU/I. Chemotherapy was given both intravenously and intrathecally. At 10 weeks, beta-HCG had returned to normal. Treatment was continued for another 10 weeks. Two years after cessation of therapy the patient is still in complete remission. In the discussion we review a scoring system to be used in selecting the mode of treatment, and briefly mention diagnosis and prognosis.