Proposed clinical management of pregnancies after combined screening for pre‐eclampsia at 19–24 weeks' gestation

Litwińska, Magdalena; Wright, David; Efeturk, Tunay; Ceccacci, I.; Nicolaides, Kypros H.

doi:10.1002/uog.17418

Cited by 27 publications

(32 citation statements)

References 17 publications

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“…We found that in pregnancies both with and without CHD that develop PE, impedance to flow in the uterine arteries is increased and this increase is particularly marked in those with preterm PE. Several previous studies have reported that, in pregnancies that develop PE, UtA-PI MoM is increased in the first, second and third trimesters and that the increase is related inversely to the gestational age at which delivery is undertaken for maternal and/or fetal indications 2,3,[9][10][11][17][18][19][20][21][22][23] . These Doppler ultrasound findings have been interpreted as supportive evidence for the results of histological studies that PE is associated with impairment of the physiological process of trophoblastic invasion of the maternal spiral arteries and their conversion from narrow muscular vessels to dilated non-muscular channels [24][25][26] .…”

Section: Main Findings Of Studymentioning

confidence: 97%

“…In PE, particularly preterm PE, there is evidence from Doppler studies of impaired uteroplacental perfusion, reflected in increased uterine artery pulsatility index (UtA‐PI). The objective of this study is to investigate further the association between fetal CHD and maternal PE by examining second‐trimester UtA‐PI in pregnancies with and those without major CDH.…”

Section: Introductionmentioning

confidence: 99%

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Impaired placental perfusion and major fetal cardiac defects

Fantasia

Andrade

Syngelaki

et al. 2018

Ultrasound in Obstet & Gyne

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Objective To investigate the relationship between fetal congenital heart defects (CHD) and placental perfusion assessed by uterine artery pulsatility index (UtA‐PI), in relation to development of pre‐eclampsia (PE). Methods This was a prospective screening study of singleton pregnancies at 19–24 weeks' gestation. Transvaginal ultrasound was used to measure UtA‐PI and the values were converted into multiples of the normal median (MoM). Median MoM values in pregnancies with a fetus with isolated major CHD were compared to those without CHD, in relation to development of PE. Results The 91 407 singleton pregnancies fulfilling the entry criteria included 206 (0.23%) with isolated major fetal CHD and 91 201 without CHD. The prevalence of PE was 4.4% in pregnancies with fetal CHD and 2.7% in those without CHD (relative risk (RR), 1.6 (95% CI, 0.84–3.04); P = 0.150); the respective values for preterm PE with delivery at < 37 weeks' gestation were 2.4% and 0.7% (RR, 3.4 (95% CI, 1.42–8.09); P = 0.006). In the total population, median UtA‐PI MoM was significantly higher in those that developed PE compared to those without PE (1.22 (interquartile range (IQR), 0.94–1.57) vs 1.00 (IQR, 0.84–1.19); P < 0.0001) and, in the PE group, the median UtA‐PI MoM was inversely related to gestational age at delivery (r = −0.458; P < 0.0001). The same pattern of inverse relationship between UtA‐PI MoM and gestational age at delivery with PE was observed in pregnancies with and those without CHD, but, in the CHD group, compared to those without CHD, UtA‐PI was significantly higher both in pregnancies with and in those without PE. Conclusions In pregnancies both with and without fetal CHD that develop PE, impedance to flow in the UtAs is increased and this increase is particularly marked in those with preterm PE. The prevalence of preterm PE is more than three times higher in pregnancies with than those without fetal major CHD, and the prevalence of major CHD in pregnancies with preterm PE is also more than three times higher than in those without PE. However, > 97% of pregnancies with fetal CHD do not develop preterm PE and > 99% of pregnancies with preterm PE are not associated with fetal CHD. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

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Section: Main Findings Of Studymentioning

confidence: 97%

Section: Introductionmentioning

confidence: 99%

Impaired placental perfusion and major fetal cardiac defects

Fantasia

Andrade

Syngelaki

et al. 2018

Ultrasound in Obstet & Gyne

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“…While aspirin commenced in the first trimester appears to reduce the development of PE, the same intervention seems ineffective when started after 20 weeks. Although it is too late to prevent the development of PE after second‐trimester prediction, the knowledge can still be useful in guiding follow‐up and management of a pregnancy at risk. However, the clinical impact of intensified follow‐up has yet to be proven.…”

Section: Management After Screeningmentioning

confidence: 99%

ISUOG Practice Guidelines: role of ultrasound in screening for and follow‐up of pre‐eclampsia

Sotiriadis

Hernández‐Andrade

Costa

et al. 2018

Ultrasound in Obstet & Gyne

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RESUMEN Pautas de práctica de ISUOG: la función del ultrasonido en la detección y seguimiento de la preeclampsia Introducción La hipertensión en el embarazo afecta hasta el 10% de las mujeres embarazadas y la incidencia global combinada de la preeclampsia (PE) es de aproximadamente el 3%. Las diferencias significativas entre los países desarrollados y en desarrollo pueden atribuirse a diferencias reales o a diferencias derivadas de la adquisición de datos. La PE y sus complicaciones contribuyen en gran medida a la morbilidad y mortalidad materna y perinatal en todo el mundo. Dado que la atención oportuna y efectiva puede mejorar los resultados de la PE, el desarrollo de estrategias eficaces de predicción y prevención ha sido uno de los principales objetivos de la atención prenatal y de la investigación. La PE es una enfermedad multisistémica de origen multifactorial: está relacionada con placentación defectuosa, estrés oxidativo, autoinmunidad, activación de plaquetas y trombina, inflamación intravascular, disfunción endotelial, desequilibrio en la angiogénesis y mala adaptación cardíaca materna. La invasión defectuosa de la placenta está fuertemente asociada con la mayoría de los casos de PE temprana y grave. En contraste, la placentación defectuosa parece ser menos importante para el desarrollo de la PE que se manifiesta más tarde en el embarazo, por ejemplo después de las 34 semanas. En comparación con los embarazos afectados por la enfermedad de aparición temprana, en aquellos complicados con PE a término o cerca de este, la frecuencia de anomalías histológicas de las placentas es significativamente menor, y los factores maternos (p. ej. el síndrome metabólico o la hipertensión crónica) tienen una importancia relativamente mayor. También se observan diferencias entre la PE de aparición temprana y la de aparición tardía en los factores de riesgo, la capacidad de respuesta vascular materna, el rendimiento del cribado y la eficacia de la prevención. El conocimiento cada vez mayor sobre la fisiopatología de la PE se refleja en las estrategias de cribado actuales, que se basan en el historial, la demografía, los biomarcadores (como la presión arterial) y el Doppler de la arteria uterina. Actualmente hay más de 10 000 artículos de PubMed relacionados con la detección de la PE, lo que indica el gran interés en este tema. Menos de una quinta parte de estos se refieren a la detección temprana, lo que constituye un avance de la última década. El objetivo de estas Pautas es revisar la evidencia más reciente y, en lo posible, proporcionar recomendaciones basadas en la evidencia con respecto a la función del ultrasonido en el cribado y seguimiento de la PE. Las Pautas se centran en los aspectos técnicos y clínicos del cribado, sin incluir los aspectos económicos y políticos de la salud, como la conveniencia y la rentabilidad del cribado. Además, estas Pautas se elaboraron partiendo del supuesto de que se dispone de los recursos necesarios para la realización del cribado y el seguimiento (equipo, examinadores y conocimient...

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“…Fourth, the competing‐risks model has been successfully applied for assessment of risk for PE and stratification of pregnancy care by a combination of maternal factors and biomarkers in the first, second and third trimesters of pregnancy. In the first trimester, the competing‐risks approach utilizing maternal factors, MAP, UtA‐PI and PlGF was used to identify women at high risk of developing preterm PE; at a 10% screen‐positive rate, 90% of early‐PE cases and 75% of those with preterm PE were predicted in both a training dataset of 35 948 singleton pregnancies and in two independent, non‐intervention, multicenter studies involving 8775 and 16 451 singleton pregnancies, respectively.…”

mentioning

confidence: 99%

“…Consequently, appropriate evaluation and application of biomarkers in screening requires prior standardization by expressing the measured values as multiples of the median (MoM) [28][29][30][31] . In pregnancies that develop PE, MoM values of MAP, UtA-PI and sFlt-1 tend to be higher and PlGF tends to be lower than in normal pregnancies; the effect size increases with increasing severity of the disease, quantified by the gestational age at delivery 5-8 .Fourth, the competing-risks model has been successfully applied for assessment of risk for PE and stratification of pregnancy care by a combination of maternal factors and biomarkers in the first, second and third trimesters of pregnancy [32][33][34][35][36][37][38][39][40][41][42][43][44] . In the first trimester, the competing-risks approach utilizing maternal factors, MAP, UtA-PI and PlGF was used to identify women at high risk of developing preterm PE; at a 10% screen-positive rate, 90% of early-PE cases and 75% of those with preterm PE were predicted in both a training dataset of 35 948 singleton pregnancies and in two independent, non-intervention, multicenter studies involving 8775 and 16 451 singleton pregnancies, respectively 32,[45][46][47][48] .…”

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confidence: 99%