PDF(Sci-hub)
Abstract：
Preeclampsia is a major cause of maternal and perinatal morbidity and mortality. Early-onset disease requiring preterm delivery is associated with a higher risk of complications in both mothers and babies. Evidence suggests that the administration of low-dose aspirin initiated before 16 weeks\' gestation significantly reduces the rate of preterm preeclampsia. Therefore, it is important to identify pregnant women at risk of developing preeclampsia during the first trimester of pregnancy, thus allowing timely therapeutic intervention. Several professional organizations such as the American College of Obstetricians and Gynecologists (ACOG) and National Institute for Health and Care Excellence (NICE) have proposed screening for preeclampsia based on maternal risk factors. The approach recommended by ACOG and NICE essentially treats each risk factor as a separate screening test with additive detection rate and screen-positive rate. Evidence has shown that preeclampsia screening based on the NICE and ACOG approach has suboptimal performance, as the NICE recommendation only achieves detection rates of 41% and 34%, with a 10% false-positive rate, for preterm and term preeclampsia, respectively. Screening based on the 2013 ACOG recommendation can only achieve detection rates of 5% and 2% for preterm and term preeclampsia, respectively, with a 0.2% false-positive rate. Various first trimester prediction models have been developed. Most of them have not undergone or failed external validation. However, it is worthy of note that the Fetal Medicine Foundation (FMF) first trimester prediction model (namely the triple test), which consists of a combination of maternal factors and measurements of mean arterial pressure, uterine artery pulsatility index, and serum placental growth factor, has undergone successful internal and external validation. The FMF triple test has detection rates of 90% and 75% for the prediction of early and preterm preeclampsia, respectively, with a 10% false-positive rate. Such performance of screening is superior to that of the traditional method by maternal risk factors alone. The use of the FMF prediction model, followed by the administration of low-dose aspirin, has been shown to reduce the rate of preterm preeclampsia by 62%. The number needed to screen to prevent 1 case of preterm preeclampsia by the FMF triple test is 250. The key to maintaining optimal screening performance is to establish standardized protocols for biomarker measurements and regular biomarker quality assessment, as inaccurate measurement can affect screening performance. Tools frequently used to assess quality control include the cumulative sum and target plot. Cumulative sum is a sensitive method to detect small shifts over time, and point of shift can be easily identified. Target plot is a tool to evaluate deviation from the expected multiple of median and the expected median of standard deviation. Target plot is easy to interpret and visualize. However, it is insensitive to detecting small deviations. Adherence to well-defined protocols for the measurements of mean arterial pressure, uterine artery pulsatility index, and placental growth factor is required. This article summarizes the existing literature on the different methods, recommendations by professional organizations, quality assessment of different components of risk assessment, and clinical implementation of the first trimester screening for preeclampsia.
摘要：
先兆子痫是孕产妇和围产期发病和死亡的主要原因。需要早产的早发性疾病与母亲和婴儿的并发症风险较高有关。有证据表明，在妊娠16周前开始服用低剂量阿司匹林可显着降低早产先兆子痫的发生率。因此,重要的是要确定孕妇在怀孕的头三个月有患先兆子痫的风险，从而允许及时的治疗干预。一些专业组织，如美国妇产科学院（ACOG）和美国国家健康与护理卓越研究所（NICE），已经提出了基于孕产妇风险因素的先兆子痫筛查。ACOG和NICE推荐的方法基本上将每个风险因素视为单独的筛查测试，具有相加的检出率和筛查阳性率。有证据表明，基于NICE和ACOG方法的先兆子痫筛查具有次优的性能，由于NICE建议仅达到41%和34%的检出率，假阳性率为10%,对于早产和足月先兆子痫，分别。基于2013年ACOG推荐的筛查对于早产和足月子痫前期只能达到5%和2%的检出率。分别,有0.2%的假阳性率。已经开发了各种前三个月预测模型。他们中的大多数没有经过或未通过外部验证。然而,值得注意的是，胎儿医学基金会(FMF)的孕早期预测模型(即三重检验)，由母体因素和平均动脉压的测量结果组成，子宫动脉搏动指数,和血清胎盘生长因子，已经经历了成功的内部和外部验证。FMF三联试验对预测早期和早产先兆子痫的检出率分别为90%和75%。分别,有10%的假阳性率。仅通过母体风险因素，这种筛查性能优于传统方法。使用FMF预测模型，随后服用低剂量的阿司匹林，已被证明可以将早产先兆子痫的发生率降低62％。通过FMF三联试验筛查预防1例先兆子痫所需的数量为250。保持最佳筛选性能的关键是建立用于生物标志物测量和常规生物标志物质量评估的标准化方案。因为不准确的测量会影响筛查性能。经常用于评估质量控制的工具包括累积总和和目标图。累积和是一种检测随时间变化的小变化的敏感方法，和转移点可以很容易地识别。目标图是评估与预期的中位数倍数和预期的标准偏差中位数的偏差的工具。目标图易于解释和可视化。然而,它对检测小偏差不敏感。遵守明确定义的平均动脉压测量协议，子宫动脉搏动指数,胎盘生长因子是必需的。本文总结了现有文献对不同方法的研究,专业组织的建议，风险评估不同组成部分的质量评估，并临床实施早孕期子痫前期筛查。
