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UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia
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UOG Journal Club: Maternal hemodynamics at 11-13 weeks’ gestation and risk of pre-eclampsia

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This Journal Club presentation provides a summary and discussion of the following free access article published in UOG: …

This Journal Club presentation provides a summary and discussion of the following free access article published in UOG:

Maternal hemodynamics at 11-13 weeks' gestation and risk of pre-eclampsia
A. Khalil, R. Akolekar, A. Syngelaki, M. Elkhouli, K. H. Nicolaides
Volume 40, Issue 1, Date: July 2012, pages 28-34

This can be accessed here:
http://onlinelibrary.wiley.com/doi/10.1002/uog.11183/abstract

Published in: Health & Medicine
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  • 1. UOG Journal Club: July 2012Maternal hemodynamics at 11–13 weeks’ gestation and risk of pre-eclampsia A. Khalil, R. Akolekar, A. Syngelaki, M. Elkhouli and K. H. Nicolaides Volume 40, Issue 1, Date: July 2012, pages 28–34 Journal Club slides prepared by Dr Asma Khalil (UOG Editor for Trainees)
  • 2. Forward flow from cardiac action Pressure Wave Reflection Blood vesselReflected flow from peripheral resistanceIncident pressure wave is generated by the heart.When the wavefront encounters resistance → Reflected waveIncident and Reflected waves → Combined waveform
  • 3. Pressure Wave ReflectionVasodilatation: Vasoconstriction: Amplitude of Reflected wave  Amplitude of Reflected waveAnd delays its return
  • 4. Pressure Wave Reflection Vasodilatation Vasoconstriction
  • 5. Central Blood Pressure Artery occluded due to suprasternal cuff pressure Forward wave 1 2 3 Pressure in Pressure waves the aorta is travel to the artery The cuff generated by are transferred to pressure is the heart the cuff measured• Aortic blood pressure (BP) ≠ brachial BP• Better prediction of vascular disease/outcome than brachial BP• Distinguishes between the effects of different antihypertensive drugs when brachial BP does not
  • 6. Augmentation index (AIx) and pulse wave velocity (PWV) are increased in pre-eclampsia (PE)Author AIx PWVPE; History of PE; PE vsgestational hypertension (GH)Hausvater et al 2012 (meta-analysis)PE predictionKhalil et al 2009, Khalil et al 2011Savvidou et al 2011 Hausvater A et al., J Hypertens 2012 Khalil A et al., BJOG 2009 Khalil A et al., Obstet Gynecol 2010 Savvidou MD et al., Am J Obstet Gynecol 2010
  • 7. Maternal hemodynamics at 11–13 weeks’ gestation and risk of pre-eclampsia Khalil et al., UOG 2012Prospective; 7,084 singleton pregnancies at 11+0 – 13+6 weeks; 2009 – 2011ObjectiveTo examine the value of maternal hemodynamics measured at11–13 weeks in the early prediction of PE
  • 8. Maternal hemodynamics at 11–13 weeks’ gestation and risk of pre-eclampsia Khalil et al., UOG 2012 Methodology• Screening for PE at 11 – 13 weeks• Comparison of history / maternal characteristics, uterineartery Doppler, PAPP-A and AIx, PWV and central systolicblood pressure (SBPAo) n • Pre-eclampsia 181 (2.6%) • Gestational hypertension 137 (1.9%) • Unaffected controls 6,766
  • 9. Methodology Inclusion criteria Vascular measurements• Singleton pregnancy and a live • Arteriograph® was used for fetus identified at 11+0 – 13+6 recording SBPAo (mmHg), PWV week scan (m/s) and AIx (%) Exclusion criteria • Results did not influence the subsequent management1) Major fetal abnormalities2) Termination of pregnancy Statistical Analysis3) Miscarriage • Multivariate logistic regression4) Fetal death before 24 weeks analysis → variables that Outcomes provided a significant contribution in predicting PE • Receiver–operating characteristics• PE (ISSHP definition) (ROC) analysis to determine the• GH performance of screening
  • 10. Maternal hemodynamics and the risk of PE Results 2.0 1.6 1.5 P<0.0001 P<0.0001 P<0.0001 P=0.051 Central aortic systolic blood pressure (MoM) P<0.0001 P<0.0001 1.4Augmentation index-75 (MoM) 1.5 Pulse wave velocity (MoM) 1.25 1.2 1.0 1.0 1.0 0.8 0.5 0.75 0.6 0.0 0.4 0.5 Normal PE GH Normal PE GH Normal PE GH
  • 11. Maternal hemodynamics and the risk of PE Performance of screening 100 90 Area under ROC curve P-valueDetection rate at FPR 10% 80 70 History 0.80 (0.79–0.81) 60 61.9% History + vascular- 0.84 (0.83–0.84) 0.005* 50 56.9% derived risk 40 47.0% 30 History + vascular- 0.85 (0.84–0.86) 0.001* derived risk + uterine 20 artery PI + PAPP-A 10 0 History + vascular + uterine PI risk + PAPP-A * Comparison with performance of screening based on maternal factors
  • 12. Maternal hemodynamics and the risk of PE Early-onset versus late-onset PE Early-onset PE Late-onset PE[History + vascular-derived risk + uterine artery PI Improvement No significant+ PAPP-A] compared to [History + vascular risk] improvementNo significant association between the vascular-derived risk for PE(combination log10 MoM of AIx-75, PVW and SBPAo) and gestational age atdelivery of the PE group.Whereas high uterine artery PI and low PAPP-A were more marked in early-PE compared to late-PE.
  • 13. Maternal hemodynamics and the risk of PE Women with chronic hypertension Superimposed PE No PE MoMs (n=21) MoMs(n=47) SBPAo 1.29 1.15* PWV 1.02 1.00 AIx-75 1.37 1.21 uterine artery PI 1.04 1.07 PAPP-A 0.92 0.84Even after exclusion of women with chronic hypertension, no significantchange in the results seen in those who developed PE [increased AIx-75,PWV, SBPao and uterine artery PI, and decrease in PAPP-A]. * p<0.05
  • 14. Maternal hemodynamics and the risk of PE Discussion Limitations Strengths • Lack of longitudinal data during•Large number•Narrow gestational range of 11- pregnancy and assessment of13 weeks, which is emerging as the patients with PE afterthe first clinical visit in pregnancy pregnancy to documentfor assessment of patient-specific whether in those with increasedrisks for a wide range of arterial stiffness and SBPaopregnancy complications there was persistence of these abnormalities
  • 15. Maternal hemodynamics and the risk of PE Discussion PE: common phenotypic expression of two distinct processes Predisposition for Impaired trophoblastic cardiovascular disease invasion Late-PE Early-PE
  • 16. Maternal hemodynamics at 11–13 weeks’ gestation and risk of pre-eclampsia Khalil et al., UOG 2012 Conclusion Women who develop PE have higher aortic systolic bloodpressure and arterial stiffness. These findings are apparent from the first trimester ofpregnancy The mechanism of association with PE does not appear tobe mediated by impaired placental perfusion and function Arterial stiffness appears promising in predicting late-PE
  • 17. Maternal hemodynamics at 11–13 weeks’ gestation and risk of pre- eclampsia Khalil et al., UOG 2012 Discussion points• What is the best screening test for identifying women at high risk of pre eclampsia?• Is this test different if the screening is performed in the first trimester or second trimester?• Is it justified to screen for pre-eclampsia?• What are the recommended indications for low-dose aspirin for prevention of pre-eclampsia?• How does screening for pre-eclampsia compare to screening for Down syndrome?• Discuss whether early-onset and late-onset pre-eclampsia have different pathologies or simply different degrees of severity of the same pathology.• Why do most of the screening markers perform better for early-onset than late- onset pre-eclampsia?• What are the potential uses of arterial stiffness in obstetrics?

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