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• W2897959632 abstract "Pautas de práctica de ISUOG: la función del ultrasonido en la detección y seguimiento de la preeclampsia 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 conocimientos especializados). Los pasos y procedimientos descritos en estas Pautas no tienen la intención de constituir un estándar legal para el servicio clínico. ISUOG实践指南:超声在子痫前期筛查和随访中的作用 妊娠期高血压疾病累及多达10%的孕妇,子痫前期(pre-eclampsia,PE)总的全球发病率约为3%。发达国家和发展中国家存在明显差异,可能是真实差异或是数据采集造成的差异所致。PE及其并发症是影响全球孕产妇围产期发病率和死亡率的一个重要因素。及时、有效的治疗能够改善PE结局,因此发展有效的预测和预防方法已经成为产前保健和研究的一个主要目标。 PE是一种多因素导致的多系统疾病:包括胎盘形成障碍、氧化应激、自身免疫、血小板和凝血酶激活、血管内炎症、内皮功能障碍、血管生成失衡、孕产妇心脏不适应。胎盘植入障碍与大多数早发型重度PE呈强相关。相反,胎盘形成障碍似乎对晚发型PE(如孕34周后)的发生影响不大。与早发型PE孕产妇相比,足月或接近足月时发生PE的孕产妇其胎盘组织学异常的发生率明显较低,母亲因素(如代谢综合征或长期高血压)具有较大意义。早发型和晚发型PE相比,危险因素、母亲血管反应、筛查能力和预防效能也存在差异。 目前的筛查方法反映了对PE病理生理学的了解逐渐加深,筛查方法是基于病史、流行病学、生物标志物(包括血压)和子宫动脉多普勒检查。 目前PubMed中收录了10 000多篇有关PE筛查的文章,表明人们非常关注这一问题。其中不到五分之一的文章探讨了早期筛查,这是过去十年取得的进展。本指南的目的是回顾最新的证据,如果可能,为超声在PE筛查和随访中的作用提供循证推荐。本指南关注筛查的技术和临床方面,并未扩展到卫生经济学和政策问题,包括筛查的可行性和成本—效益。而且指南的制定是假设能够获得筛查和随访所需的资源(设备、检查人员、专家)。本指南中所描述的步骤和程序并不是作为临床服务的法律标准。 The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scientific organization that encourages sound clinical practice, and high-quality teaching and research related to diagnostic imaging in women's healthcare. The ISUOG Clinical Standards Committee (CSC) has a remit to develop Practice Guidelines and Consensus Statements as educational recommendations that provide healthcare practitioners with a consensus-based approach, from experts, for diagnostic imaging. They are intended to reflect what is considered by ISUOG to be the best practice at the time at which they were issued. Although ISUOG has made every effort to ensure that Guidelines are accurate when issued, neither the Society nor any of its employees or members accepts any liability for the consequences of any inaccurate or misleading data, opinions or statements issued by the CSC. The ISUOG CSC documents are not intended to establish a legal standard of care, because interpretation of the evidence that underpins the Guidelines may be influenced by individual circumstances, local protocol and available resources. Approved Guidelines can be distributed freely with the permission of ISUOG (info@isuog.org). Hypertensive disease of pregnancy affects up to 10% of pregnant women1 and the pooled global incidence of pre-eclampsia (PE) is approximately 3%2. Significant variations between developed and developing countries can be attributed to true differences or differences arising from data acquisition. PE and its complications are a major contributor to maternal and perinatal morbidity and mortality worldwide1, 3. Given that timely and effective care can improve the outcome of PE3, the development of effective prediction and prevention strategies has been a major objective of prenatal care and of research. PE is a multisystemic disease of multifactorial origin: it involves defective placentation, oxidative stress, autoimmunity, platelet and thrombin activation, intravascular inflammation, endothelial dysfunction, an imbalance in angiogenesis and maternal cardiac maladaptation4, 5. Defective placental invasion is associated strongly with most cases of early and severe PE4. In contrast, defective placentation seems to be less important for the development of PE that manifests later in pregnancy, for example after 34 weeks. Compared with pregnancies affected by early-onset disease, in those complicated with PE at or near term, placentae have a significantly lower frequency of histological abnormalities6, and maternal factors (e.g. metabolic syndrome or chronic hypertension) have a relatively greater significance4. Differences between early- and late-onset PE are also seen in risk factors7, maternal vascular responsiveness8, screening performance9 and prevention effectiveness10. Increasing insight into the pathophysiology of PE is reflected in current screening strategies, which are based on history, demographics, biomarkers (including blood pressure) and uterine artery Doppler11. There are currently more than 10 000 PubMed-indexed articles related to PE screening, illustrating the vast interest in this topic. Fewer than one-fifth of these deal with early screening, this being a development of the last decade. The aim of these Guidelines is to review the latest evidence and, when possible, provide evidence-based recommendations regarding the role of ultrasound in screening and follow-up of PE. The Guidelines focus on the technical/clinical aspects of screening, without extending to health economics and policy issues including the advisability and cost-effectiveness of screening. Moreover, these Guidelines were developed with the assumption that the resources required for implementation of screening and follow-up (equipment, examiners, expertise) are available. The steps and procedures described in these Guidelines are not intended to act as a legal standard for clinical service. Although the terms ‘screening’ and ‘prediction’ are frequently used interchangeably, screening is in fact a wider process, beginning with invitation of a population to participate and ending with treatment for individuals identified as being at high risk12. Prediction, or the calculation of risk for disease, is an integral element of the screening process, but it is not equivalent to screening, as the latter also involves an intervention that is offered to individuals at high risk, and aims to alter the natural history of the screened condition and ultimately to improve the outcome13. Screening in prenatal care has been commonly used to offer the option of timely termination of pregnancy to parents of fetuses with untreatable conditions; this is an extension of the World Health Organization's scope of screening, which is prevention of disease. For the purpose of these Guidelines, in the context of PE, ‘screening’ is the preferred term when identification of cases at risk may lead to prevention of its development, whereas ‘prediction’ is the preferred term when there is no evidence that identification of women at risk will eventually improve their outcome. Given that ultrasound screening for PE should not be isolated from the general concept of prenatal care, it is advisable that professionals who screen for PE have up-to-date knowledge about proven risk factors and aim to identify them during screening. A global assessment of risk should encompass four broad areas, including personal risk profile (including age, ethnicity, parity, smoking, medical and obstetric history and conception method), metabolic risk profile (including body mass index (BMI) and history of diabetes), cardiovascular risk profile (including existing cardiovascular conditions and measurement of mean arterial blood pressure) and placental risk profile (including uterine artery Doppler and maternal serum biomarkers)11. The use of ultrasound as a tool for screening/prediction of PE is based on the fact that defective placentation results in incomplete transformation of the spiral arteries. Placental villous and vascular histopathological lesions are four-to-seven times more common in PE than in non-PE pregnancies14 and are associated with increased resistance to uterine artery blood flow15. Measurement of impedance (or resistance) to flow in the uterine arteries by Doppler assessment thus renders quantifiable the incomplete transformation of the spiral arteries. As described in the ISUOG Practice Guidelines on the use of Doppler ultrasonography in obstetrics16, the systolic/diastolic ratio (S/D), resistance index (RI) and PI are the three best-known indices with which to describe arterial flow-velocity waveforms. PI is the index most commonly used; its advantage over RI in evaluation of the uterine artery Doppler waveform is that PI includes in its calculation the averaged value of all maximum velocities during the cardiac cycle, rather than just two points in the cardiac cycle as for RI. Furthermore, PI is more stable and it does not approach infinity when there are absent or reversed diastolic values16. Uterine artery notching has also been used in screening for PE17, the presence of bilateral notches being associated with indications of maternal endothelial dysfunction (lower flow-mediated dilatation of the brachial artery)18. Despite its theoretical plausibility as a screening marker, bilateral notching is not uncommon in normal first-trimester pregnancies, occurring in 43% of cases19, which reduces its specificity. Likewise, uterine artery notching in the second trimester has similar sensitivity to that of increased PI, but for a higher screen-positive rate17, and there may be a degree of subjectivity in defining notching, which further limits the value of this finding as a screening marker. A 2008 meta-analysis indicated that increased PI, alone or combined with notching, is the most predictive Doppler index for PE20. A considerable amount of evidence published since then indicates the superiority of mean uterine artery PI as the preferred Doppler index for PE screening, and this is the index used for screening and prevention in the first trimester21-23. Doppler examination of the uterine arteries has been studied most extensively in the period from 11 + 0 to 13 + 6 weeks. This is a common time for first-trimester ultrasound examination in many countries, and therefore practical in terms of logistics. Earlier assessment has not been studied extensively because trophoblast invasion is not yet sufficiently advanced as to be assessable. For the first-trimester transabdominal assessment of uterine artery resistance, a midsagittal section of the uterus and cervix is obtained initially. Using color flow mapping, the transducer is gently tilted sideways, so that the uterine arteries are identified with high-velocity blood flow along the side of the cervix and uterus (Figure 1). The pulsed-wave Doppler sampling gate should be narrow (set at approximately 2 mm) and positioned on either the ascending or descending branch of the uterine artery at the point closest to the internal cervical os, with an insonation angle < 30°24. In order to verify that the uterine artery is being examined, the peak systolic velocity should be > 60 cm/s. The PI is measured when at least three identical waveforms are obtained25, 26. Detailed methodology can be found in a practical advice paper published in this journal27. Following this approach, uterine artery PI can be measured in more than 95% of cases25. Transvaginal assessment of uterine artery resistance follows the same principles. The woman is placed in the lithotomy position, with her bladder empty, and a transvaginal probe is used to obtain a sagittal view of the cervix. The probe is then moved laterally until the paracervical vascular plexus is seen, and the uterine artery is identified at the level of the internal cervical os. Measurements are taken with an angle of insonation < 30°28. Adherence to a standardized methodology is essential to ensure reproducible measurements. Studies evaluating the reproducibility of this technique have shown interobserver intraclass/concordance correlation coefficients of 0.80–0.8529, 30. However, limits of agreement were found be as high as ± 35% for the transvaginal and ± 40% for the transabdominal approach30. On this basis, the reproducibility of the method should be interpreted as being poor to moderate31. Besides differences caused by observers, Doppler indices may change during an examination, due to factors such as uterine contractions and changes in heart rate. Although the effect of such factors cannot be prevented, adherence to a standardized protocol of examination27 is imperative to minimize the operator-dependent variability, as systematic error in measurements can affect the screen-positive rate32. The 95th centile of mean uterine artery PI obtained using a transabdominal approach is about 2.35 for the period 11 + 0 to 13 + 6 weeks25, with no change25 or only a small trend to decrease30 over this period. In two comparative studies30, 33, the transvaginal approach gave significantly higher readings compared with the transabdominal approach, with mean PIs of 1.98 vs 1.8333 and 1.60 vs 1.5230. The reason for this may be that transvaginal ultrasound allows closer proximity of the transducer to the vessel and lower insonation angles30. The 95th centile of the mean uterine artery PI obtained transvaginally has been reported as approximately 3.10 for CRLs up to 65 mm, progressively declining thereafter to reach 2.36 at a CRL of 84 mm33. In women who do not develop PE, uterine artery PI may be affected by maternal factors, including ethnic origin (African origin is associated with increased PI), BMI (decreasing PI with increasing BMI) and previous PE (associated with increased PI)26. The association between decreasing PI and increasing BMI is not clear; the vasodilatory effect of increased levels of estrogens in these women on the uterine circulation has been postulated as a potential cause26, 34. An absolute numerical cut-off for uterine artery PI may, therefore, not reflect accurately uterine artery resistance, and it has been suggested that first-trimester uterine artery PI should be expressed as multiples of the median (MoM) rather than absolute values35. In one of the early studies using the current standard methodology for assessing uterine artery Doppler in the first trimester, a mean PI > 95th centile had a sensitivity of 27% for PE and a sensitivity of 60% for PE requiring delivery before 32 weeks25. Subsequent studies used the lowest uterine artery PI (i.e. PI of the side with least resistance) because the point estimates for the area under the receiver–operating characteristics curve (AUC) were marginally better when the lowest rather than the mean PI was used in the regression model (0.91 vs 0.90 for early PE)36. However, the confidence intervals for the AUCs overlapped, and the superiority of the lowest PI was not confirmed by another large study (AUC, 0.79 for mean and 0.76 for lowest PI for the outcome of early PE, with overlapping CIs)37. Both techniques are acceptable, but the mean uterine artery PI is the index most commonly used for first- and second-trimester uterine artery Doppler examination, and the default reference values in most commercial software apply to this. Bilateral notching has been associated with a 22-fold increased risk for PE and an almost nine-fold increased risk for small-for-gestational-age (SGA) neonate38; however, it may be observed in around 50% of pregnant women at 11 + 0 to 13 + 6 weeks19, 25, 39. This marker therefore has a very low specificity for PE. A recent meta-analysis reported that first-trimester Doppler examination of the uterine arteries can predict 47.8% of cases of early PE (7.9% false-positive rate), 39.2% of cases of early fetal growth restriction (6.7% false-positive rate) and 26.4% of cases of PE at any stage (6.6% false-positive rate), when using as a cut-off the 90th centile of PI or RI40. However, combined screening (including maternal factors, maternal mean arterial blood pressure, uterine artery Doppler and placental growth factor (PlGF) measurement) has superior predictive performance (as detailed later) and, if available, should be preferred over Doppler-based screening. Uterine artery flow resistance can be assessed either transabdominally or transvaginally. The transabdominal technique is similar to that of the first trimester, the main difference being that right and left uterine arteries are identified at the apparent crossover with the external iliac arteries, rather than paracervically. After the arteries are identified, pulsed-wave Doppler is used to obtain the waveforms. When at least three similar consecutive waveforms are obtained, PI is measured, and the presence or absence of early diastolic notching is recorded41. In the transvaginal technique, the woman is asked to empty her bladder and is placed in the dorsal lithotomy position. The ultrasound probe is inserted into the anterior fornix, and the cervix is identified in the midsagittal plane. The probe is then moved into the lateral fornix and the uterine arteries are identified on either side using color Doppler at the level of the internal cervical os. Pulsed-wave Doppler is used to obtain three similar consecutive waveforms. PI can then be measured and the presence or absence of early diastolic notching can be recorded17. Examination of the uterine artery Doppler waveform following this approach is feasible in 99% of women42. As in the first trimester, using either a transabdominal or a transvaginal approach, care should be taken to maintain the angle of insonation < 30° and the peak systolic velocity > 60 cm/s to ensure that the uterine artery rather than the arcuate artery is being examined24. Similar to the first trimester, when the uterine arteries are examined transvaginally, the PI readings are higher compared with those obtained using the transabdominal approach. In a comparative series of 96 women between 20 and 26 weeks, the mean uterine artery PI was 1.07 with the transvaginal and 0.96 with the transabdominal approach. The median angle of insonation was lower using transvaginal ultrasound (10.0° vs 17.5°); however, PI being a ratio, the most likely reason for the differences between transabdominal and transvaginal values is the different anatomical location of the examination. Both techniques have similar reproducibility (interobserver concordance coefficient, 0.86 vs 0.81; limits of agreement, ± 35%)30. The 95th centile of the mean uterine artery PI at 23 weeks obtained with a transabdominal approach has been reported as 1.4441, and that obtained with a transvaginal approach as 1.5843. The 95th centile of the mean uterine artery PI decreases by about 15% between 20 and 24 weeks, and by < 10% between 22 and 24 weeks44. In unilaterally located placentae, resistance to uterine flow on the contralateral side is commonly increased. A unilaterally increased PI does not appear to be associated with a higher risk for PE if the mean PI is within normal limits45. The predictive performance of uterine artery Doppler is better for early-onset PE; a study of more than 32 000 women indicated that, for a false-positive rate of 10%, uterine artery PI alone can predict 85% of cases of early-onset PE, compared with 48% of late-onset cases when combined with maternal factors46. Furthermore, the risk for early PE appears to increase with increasing uterine artery resistance; a mean PI of 1.6 was associated with a positive likelihood ratio (LR+) of 3.07, a mean PI of 1.8 with a LR+ of 8.00 and a mean PI of 2.2 with a LR+ of 27.08 (transvaginal measurements)46. In general, uterine artery Doppler velocimetry tends to predict better the more severe and complicated cases. For example, mean PI >1.65 (on transvaginal ultrasound) was found to predict 41% of all PE cases, but, when subgroups were analyzed, the prediction rate was 69% for PE with fetal growth restriction and 24% for PE with normal fetal growth17. This finding can be explained by the fact that high impedance in the uterine arteries reflects defective placentation, which has a concomitant deleterious effect on fetal growth. Bilateral diastolic notching in the uterine artery Doppler waveform is also associated with increased risk for PE17, 41, 42, 46, 47. However, for the same false-positive rate, uterine artery PI is associated with better sensitivity than is notching42, rendering unnecessary its addition to screening, although not all studies support this47. In terms of maternal health, a study of 491 women undergoing transthoracic echocardiography at the time of second-trimester screening for PE, showed that women with mean uterine artery PI > 90th centile (which was 1.25 in that study) had a higher prevalence of previously undiagnosed, functionally significant, cardiac defects (4.4%) compared with women with normal mean uterine artery PI (0.3%). This prevalence was particularly high among migrant women48. The standard method for Doppler examination of the uterine arteries in the third trimester is by a transabdominal approach, similar to the second trimester24, 41. In a large, multicenter study in the UK, the 90th and 95th centiles for mean uterine artery PIs between 30 + 0 and 34 + 6 weeks were 1.03 and 1.17, respectively49. Mean uterine artery PI > 95th centile (5% false-positive rate) alone could predict 54% of PE before 37 weeks and 14% of PE ≥ 37 weeks. The corresponding rates for mean PI > 90th centile (10% false-positive rate) were 68% and 14%, respectively, highlighting the poor performance of Doppler studies alone in predicting term PE49. The same group assessed the effectiveness of screening at 35–37 weeks, finding that uterine artery Doppler alone was a poor predictor for PE; even when it was combined with maternal factors, the detection rate was 26% for a 5% false-positive rate and 37% for 10% false-positive rate50. Reversed uterine artery diastolic flow has been reported sporadically in the third trimester and, in cases with placental insufficiency, was associated with adverse outcome, such as progression to eclampsia or intrauterine demise51, 52. As well as cross-sectional measurements of Doppler indices, their longitudinal changes have been studied in the prediction of PE. A study examining sequentially uterine artery Doppler at 11–14 and 19–22 weeks (n = 870) reported that 73% of cases with increased PI in the first trimester had normalized by the second trimester. Women with increased PI in both first and second trimesters were at highest risk (37.5%) for adverse pregnancy outcome, i.e. growth restriction or hypertensive disorder. In contrast, women with normal PI in the first trimester had a 95% chance of normal measurements in the second trimester, and this was the group with the lowest incidence of adverse outcome (5.3%)53. Another index that has been tested is the difference between second-trimester and first-trimester uterine artery PI, both expressed in MoM for the corresponding gestational ages. An increasing gap between first- and second-trimester uterine artery PI MoM, reflecting defective spiral artery transformation, appeared to be the most accurate predictor for early (AUC, 0.85) and preterm (AUC, 0.79) PE54. Another study on 104 women with increased uterine artery PI at 20–22 weeks reported that abnormal findings persisted at 26–28 weeks in 59.6% of cases; women with persistently increased PI had a greater risk for PE (16% vs 1%), SGA (32% vs 1%) and admission to a neonatal intensive care unit (26% vs 4%), compared with women in whom the PI normalized55. A problem with sequential assessment of Doppler is that the window of opportunity for preventative intervention (i.e. gestational age < 16 weeks) is missed if intervention is delayed pending a subsequent scan. Shortly after the introduction of three-dimensional ultrasound, first-trimester placental volume was tested as a potential predictor of PE. In one of the initial studies, placental volume at 12 weeks was compared with uterine artery Doppler examination at 22 weeks; the predictive performances of these two methods were: 20% and 28%, respectively, for PE without SGA; 31% and 46%, respectively, for PE with SGA; and 50% and 50%, respectively, for early PE56. Similarly, placental volume had predictive performance comparable to that of first-trimester mean uterine artery PI for PE (56% vs 50%) and for PE requiring delivery before 32 weeks (67% vs 67%)57. However, these findings have not been confirmed by other studies58, 59. Three-dimensional placental vascularization indices have also been evaluated58-62; however, they can be affected by attenuation due to depth and tissue interfaces, the use of different ultrasound settings and the lack of robust reproducibility (intra- and interobserver intraclass correlation coefficients, < 0.48 and < 0.66, respectively)63, all of which limit their clinical applicability. Although good reproducibility is reported for placental volume calculation64, 65, normal values vary considerably (first-trimester mean placental volume has been reported to range from 45 to 74 mL59, 61, 64-66). Moreover, placental volume calculation is currently a non-automated measurement subject to operator variability, and can be time-consuming, depending on the number of frames used for volume analysis67. Maternal risk factors (history, demographics, cardiovascular and metabolic profile) and placental markers (uterine artery resistance and biomarkers) for the development of PE have been identified. Therefore, the current trend in screening involves combining the presence or absence of multiple risk factors in order to calculate a personalized risk and then tailoring management accordingly, similar to screening for chromosomal abnormalities11. On a population basis, combined screening aims at improving on the sensitivity of single-marker screening and, at the same time, reducing the false-positive rate. Combined screening has been the subject of approximately 400 PubMed articles up to April 2018. Multiple studies have shown that women who go on to develop PE have, on average, higher mean arterial pressure68, higher concentrations of maternal serum soluble fms-like tyrosine kinase-1 (sFlt-1)69, 70 and alpha-fetoprotein (AFP)71, and lower concentrations of pregnancy-associated plasma protein-A (PAPP-A)72 and PlGF70, 73, along with higher resistance in the uterine arteries74, compared with women who do not. For all these predictors, the performance was better for early than for late PE9, 70, and was better when assessed later in pregnancy than at 11–13 weeks, i.e. closer to the development of PE68-71, 73-75. Data from almost 36 000 prospectively followed singleton pregnancies showed that, at a false-positive rate of 10%, maternal factors alone (including age, weight, ethnic origin, reproductive and medical history and smoking) could predict 49% of PE < 37 weeks. The addition of PlGF increased this rate to 60%, and combined screening with maternal characteristics, mean uterine artery PI, mean arterial pressure and PlGF at 11–13 weeks predicted 75% of cases of PE < 37 weeks and 47% of cases of PE ≥ 37 weeks9. The same protocol was used in the context of the ASPRE trial21, 76; in this trial, combined screening was followed by randomization to aspirin or placebo in those at high risk. This algorithm, combining maternal factors, mean arterial pressure, mean uterine artery PI and PlGF, achieved a 100% detection rate for PE developing < 32 weeks, 75% detection for PE developing < 37 weeks and 43% detection for PE developing ≥ 37 weeks, for a 10% false-positive rate. The fetal fraction of cell-free DNA in the maternal circulation is also significantly associated with maternal and fetal risk factors for PE, and there is a significant relationship between low fraction and increased risk for PE77; however, its impact on first-trimester screening has not been evaluated in prospective studies. Similar to the fir" @default.
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• W2897959632 title "ISUOG Practice Guidelines: role of ultrasound in screening for and follow‐up of pre‐eclampsia" @default.
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