The Fetal Medicine Foundation (2024)

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<main class="mt-2 flex"> <div class="text-center sticky top-2 left-2 hidden xl:block flex-shrink-0 " style="width: 160px; height: 600px;" > <ins class="adsbygoogle adsense h-ad4 " data-ad-client="ca-pub-9137371106135127" style="display:block" data-ad-format="auto" data-ad-slot="2246212396" data-full-width-responsive="true" data-adtest="off" > </ins> <script> (adsbygoogle = window.adsbygoogle || []).push({}); </script> </div> <div class="main-container container"> <main class="left-container doc-detail"> <section class="hentry flex items-center md:items-start mt-3 md:mt-3 ml-0 flex-col md:flex-row"> <div class="w-full"> <h1 class="entry-title mb-5 text-center font-semibold text-2xl xl:text-4xl !leading-common"> The Fetal Medicine Foundation (2024) </h1> <div class="bg-primary-100 text-common !leading-common rounded-lg pl-5 pr-2 py-4 mb-2 space-y-2 text-primary-500"> <div class="font-semibold">Table of Contents</div> <a class="list-item toc-h3" href="#toc-0">Risk assessment</a> <a class="list-item toc-h2" href="#toc-1">Assessment of risk for preeclampsia (PE)</a> <a class="list-item toc-h3" href="#toc-2">Clinical application</a> <a class="list-item toc-h3" href="#toc-3">Measurement of biomarkers</a> <a class="list-item toc-h3" href="#toc-4">Audit of results</a> </div> <div class="text-center my-2 sm:my-4 " > <ins class="adsbygoogle adsense h-ad3 " data-ad-client="ca-pub-9137371106135127" style="display:block" data-ad-format="auto" data-ad-slot="2246212396" data-full-width-responsive="true" data-adtest="off" > </ins> <script> (adsbygoogle = window.adsbygoogle || []).push({}); </script> </div> <article class="article-detail"> <section class="entry-content paragraph"><div> <section> <div> <header> <h3 id="toc-0">Risk assessment</h3> <h2 id="toc-1">Assessment of risk for preeclampsia (PE)</h2> </header> <div> <div> <p> This application uses Bayes theorem to combine the <em>prior</em> risk from maternal factors and medical history with the results of various biophysical and biochemical measurements to estimate the <em>posterior</em> risk for PE. You can obtain risks for PE based on maternal factors alone and in combination with any of the biomarkers. </p> <h3 id="toc-2">Clinical application</h3> <h4>Screening for PE at 11-14 weeks <sup><span>1</span></sup></h4> <ul> <li>The objective of screening at this stage is the identification of a group at high-risk for preterm-PE (<37 weeks) and the reduction of such risk through the prophylactic use of aspirin (150 mg/day from 11-14 to 36 weeks). The ASPRE trial has shown that in pregnancies at high-risk for PE administration of aspirin reduces the rate of early-PE (<32 weeks) by about 90% and preterm-PE by 60%. Prophylactic use of aspirin does not reduce the incidence of term-PE <sup><span>2</span></sup>.</li> <li>Combined screening by maternal factors, uterine artery PI, mean arterial pressure and serum PLGF can predict 90% of early-PE and 75% of preterm-PE, at screen positive rate (SPR) of 10% (<span>Table 1</span>). Inclusion of PAPP-A does not provide significant improvement to any combination of biomarkers which include serum PLGF.</li> <li>In a White population, for risk cut-off of 1 in 100 and 1 in 150 the respective SPR’s are about 10% and 16%, the DR’s for early-PE are 88% and 94% and DR’s for preterm-PE are 69% and 81%. It would therefore be reasonable in screening for PE in a setting with a predominantly White population to use a risk cut-off of 1 in 150 to define the high-risk group that would benefit from prophylactic use of aspirin. However, at such risk cut-off it should be anticipated that for Black women the SPR would be about 40% with DR of early- and preterm-PE of 100% and 95%, respectively. This is an inevitable consequence of the fact that the prevalence of preterm-PE is more than three times as high in Black than White women.</li> </ul> <h4>Screening for PE at 19-25 weeks <sup><span>3</span></sup></h4> <p>Screening at this stage should ideally be by a combination of maternal factors, uterine artery PI, mean arterial pressure and serum PLGF and the risk for PE <32 weeks and PE <36 weeks should be calculated. On the basis of these risks the women are stratified into high-, intermediate- and low-risk management groups. The high-risk group would require close monitoring for high blood pressure and proteinuria at 24-31 weeks. The intermediate-risk group together with the undelivered pregnancies from the high-risk group, would have reassessment of risk for PE at 32 weeks to identify those that would require close monitoring for high blood pressure and proteinuria at 32-35 weeks.</p> <ul> <li>At risk cut-off of 1 in 25 for PE <32 weeks, 1% of the population would be stratified into the high-risk group which will contain nearly all cases that will develop PE at <32 weeks; these patients need close monitoring at 24-31 weeks.</li> <li>At risk cut-off of 1 in 150 for PE <36 weeks, 10% of the population would be stratified into the intermediate-risk group which will contain about 90% of cases that will develop PE at 32-36 weeks; these patients need reassessment at 32 weeks.</li> <li>All pregnancies would have reassessment of risk for PE at 35-37 weeks to define the high-risk group for term-PE.</li> </ul> <h4>Screening for PE at 30-35 weeks</h4> <p>Screening at this stage should ideally be by a combination of maternal factors, uterine artery PI, mean arterial pressure, serum PLGF and serum sFLT-1.<div class="sm:flex sm:items-center sm:justify-center sm:flex-row sm:space-x-1 insert" style="margin-top:0; margin-bottom:0;"><ins class="adsbygoogle sm:w-1/2" style="display:block; text-align:center;" data-ad-layout="in-article" data-ad-format="fluid" data-full-width-responsive="true" data-ad-slot="2246212396" data-ad-client="ca-pub-9137371106135127" data-adtest="off"></ins><script>(adsbygoogle = window.adsbygoogle || []).push({});</script><ins class="adsbygoogle sm:w-1/2" style="display:block; text-align:center;" data-ad-layout="in-article" data-ad-format="fluid" data-full-width-responsive="true" data-ad-slot="2246212396" data-ad-client="ca-pub-9137371106135127" data-adtest="off"></ins><script>(adsbygoogle = window.adsbygoogle || []).push({});</script></div></p> <ul> <li>At risk cut-off of 1 in 150 for PE <36 weeks, 10% of the population would be stratified into the high-risk group which will contain nearly all cases that will develop PE at 32-36 weeks; these patients need close monitoring for high blood pressure and proteinuria at 32-35 weeks.</li> <li>All pregnancies would have reassessment of risk for PE at 35-37 weeks to define the high-risk group for term-PE.</li> </ul> <h4>Screening for PE at 35-38 weeks <sup><span>4</span></sup></h4> <p>Screening at this stage should ideally be by a combination of maternal factors, mean arterial pressure, PLGF and sFLT-1.</p> <ul> <li>At risk cut-off for PE at <42 weeks of 1 in 30 the detection rate of term-PE is 75% at SPR of 13%. The rationale for such late third-trimester screening is identification of a high-risk group that would benefit from close monitoring to minimize adverse perinatal events for those that develop PE by determining the appropriate time and place for delivery.</li> </ul> <h3 id="toc-3">Measurement of biomarkers</h3> <ul> <li>Technique for measurement of mean arterial pressure: please <span>click here</span>.</li> <li>Technique for measurement of uterine artery PI: please <span>click here</span>.</li> <li>Measurement of biochemical markers requires validated equipment and reagents. At present these are provided by DelfiaXpress from PerkinElmer, Kryptor from ThermoFisher and Elecsys from Roche.</li> <li>All measurements for biophysical and biochemical markers are expressed as multiples of the normal median (MoMs), adjusting for maternal factors that provide substantive contribution to their value. This application allows calculation of MoMs from the measurements of biomarkers. In the case of biochemical markers you may prefer to record the MoM values obtained from your laboratory.</li> </ul> <h3 id="toc-4">Audit of results</h3> <p>To ensure that the service you provide is of high quality it is important that you audit the distribution of your mean arterial pressure and uterine artery PI measurements and MoM values of PAPP-A, PLGF and sFLT-1 at regular intervals.</p> <ul> <li>To audit the distribution of mean arterial pressure measurements please <span>click here</span>.</li> <li>To audit the distribution of uterine artery PI measurements please <span>click here</span>.</li> <li>To audit the distribution of MoM values of PAPP-A please <span>click here</span>.</li> <li>To audit the distribution of MoM values of PLGF please <span>click here</span>.</li> <li>To audit the distribution of MoM values of sFLT-1 please <span>click here</span>.</li> </ul> <p>The median MoM value for each biomarker should be approximately 1.0 MoM. The audit function will highlight whether your values are outside acceptable limits:</p> <ul> <li>In the case of mean arterial pressure and uterine artery PI, you may need to retrain in taking appropriate measurements.</li> <li>In the case of biochemical markers, you should review the process of collection and transportation of samples to the laboratory and whether the laboratory uses the appropriate software and adjustments in the calculation of MoMs.</li> </ul> <p>To use the application please <span>click here</span>.</p> <h4>References</h4> <ol> <li>Tan MY, Syngelaki A, Poon LC, Rolnik DL, O'Gorman N, Delgado JL, Akolekar R, Konstantinidou L, Tsavdaridou M, Galeva S, Ajdacka U, Molina FS, Persico N, Jani JC, Plasencia W, Greco E, Papaioannou G, Wright A, Wright D, Nicolaides KH. Screening for pre-eclampsia by maternal factors and biomarkers at 11-13 weeks' gestation. Ultrasound Obstet Gynecol 2018; 52: 186-195.</li> <li>Rolnik DL, Wright D, Poon LC, O'Gorman N, Syngelaki A, de Paco Matallana C, Akolekar R, Cicero S, Janga D, Singh M, Molina FS, Persico N, Jani JC, Plasencia W, Papaioannou G, Tenenbaum-Gavish K, Meiri H, Gizurarson S, Maclagan K, Nicolaides KH. Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med 2017; 377: 613-622.</li> <li>Litwinska M, Syngelaki A, Wright A, Wright D, Nicolaides KH. Management of pregnancies after combined screening for pre-eclampsia at 19-24 weeks' gestation. Ultrasound Obstet Gynecol. 2018; 52: 365-372.</li> <li>Panaitescu A, Ciobanu A, Syngelaki A, Wright A, Wright D, Nicolaides KH. Screening for preeclampsia at 35–37 weeks’ gestation. 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