UOG Journal Club: September 2013
Value of adding second-trimester uterine artery Doppler to patient
characteristics in ide...
• Accurate prediction of pre-eclampsia (PE) in early pregnancy
would allow for timely allocation of monitoring resources, ...
Value of adding second-trimester uterine artery Doppler to patient
characteristics in identification of nulliparous women ...
• The IPD-POPULAR project relies on a systematic search of the literature,
invitations to share data and a comparison of m...
• The analysis performed in the present study was restricted to nulliparous
women who had had a 2nd trimester UtAD
• The r...
Results
MEDLINE and EMBASE search (1995-2009) resulted in
3199 citations
22 authors did not share data despite
an expresse...
• Mean PI performed better than lower and higher PI (although this
was not statistically significant)
• Mean RI performed ...
The discriminative ability of the models including both patient characteristics and Doppler
parameters was significantly b...
The model with BMI, mean RI and bilateral
notching showed good calibration.
Women in the two deciles with highest
calculat...
The discriminative ability of the models predicting pre-eclampsia requiring delivery
before 34 weeks was significantly imp...
Women ranked in the highest centiles of predicted probabilities from both models
delivered earlier than women with lower p...
Discussion
• In nulliparous women, the combination of Doppler ultrasound
parameters and bilateral notching significantly i...
Limitations
• As all studies included were primarily designed to investigate
uterine artery Doppler, the number and type o...
Discussion points
• How can the results of this meta-analysis be applied in clinical practice?
• In the light of the prese...
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UOG Journal Club: Second-trimester uterine artery Doppler in risk for pre-eclampsia

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UOG Journal Club: September 2013

Value of adding second-trimester uterine artery Doppler to patient characteristics in identification of nulliparous women at increased risk for pre-eclampsia: an individual patient data meta-analysis

C. E. Kleinrouweler, P. M. M. Bossuyt, B. Thilaganathan, K. C. Vollebregt, J. Arenas Ramírez, A. Ohkuchi, K. L. Deurloo, M. Macleod, A. E. Diab, H. Wolf, J. A. M. van der Post, B. W. J. Mol and E. Pajkrt

Volume 42, Issue 3, Date: September 2013, pages 257–267

Link to the free-access article:
onlinelibrary.wiley.com/doi/10.1002/uog.12435/abstract

Published in: Technology, Business
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  • Hooray finally. However misleading. Uterine artery doesn't reach maturity until 26 weeks, Mean and 2+/- sd. Should not be restricted to primparas. AJOG 1987;157;680-5.
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UOG Journal Club: Second-trimester uterine artery Doppler in risk for pre-eclampsia

  1. 1. UOG Journal Club: September 2013 Value of adding second-trimester uterine artery Doppler to patient characteristics in identification of nulliparous women at increased risk for pre-eclampsia: an individual patient data meta-analysis C. E. Kleinrouweler, P. M. M. Bossuyt, B. Thilaganathan, K. C. Vollebregt, J. Arenas Ramírez, A. Ohkuchi, K. L. Deurloo, M. Macleod, A. E. Diab, H. Wolf, J. A. M. van der Post, B. W. J. Mol and E. Pajkrt Volume 42, Issue 3, Date: September 2013, pages 257–267 Journal Club slides prepared by Dr Aly Youssef (UOG Editor for Trainees)
  2. 2. • Accurate prediction of pre-eclampsia (PE) in early pregnancy would allow for timely allocation of monitoring resources, with the prospect of improving maternal and perinatal outcomes • Doppler ultrasound can be used to assess blood flow velocity in the maternal uterine arteries and thus potentially identify pregnancies at increased risk for pre-eclampsia • There is uncertainty about the prognostic accuracy of Doppler ultrasound findings, when combined with more readily available patient characteristics such as blood pressure and weight
  3. 3. Value of adding second-trimester uterine artery Doppler to patient characteristics in identification of nulliparous women at increased risk for pre- eclampsia: an individual patient data meta-analysis Kleinrouweler et al., UOG 2013 The aim of the present individual patient data (IPD) meta-analysis was to investigate the added value of uterine artery Doppler (UtAD) measurements in the identification of nulliparous women at risk for pre-eclampsia, based on analyses of individual patient data from previously published studies
  4. 4. • The IPD-POPULAR project relies on a systematic search of the literature, invitations to share data and a comparison of multivariable prediction models for pre-eclampsia in these data • A MEDLINE and EMBASE search was conducted between 1995-2009 to identify eligible studies • Studies were eligible if UtAD was performed at any gestational age, at any level of risk for pre-eclampsia and in which gestational age at ultrasound, Doppler ultrasound findings and the occurrence of pre- eclampsia had been recorded • The corresponding authors of eligible studies were invited to participate in the project and share their original datasets Methods: Literature search, study selection, data collection and quality assessment
  5. 5. • The analysis performed in the present study was restricted to nulliparous women who had had a 2nd trimester UtAD • The relationship between each patient characteristic or Doppler ultrasound parameter and pre-eclampsia was evaluated by univariable logistic regression analysis • Identification of the best predictive patient characteristic or combination of patient characteristics, and the best predictive Doppler parameter, or combination of Doppler parameters, was performed • Models consisting only patient characteristics, Doppler parameters only, and a model containing both patient characteristics and Doppler ultrasound findings were compared • Model discrimination was assessed by calculating the area under the curve (AUC) in a receiver–operating characteristics (ROC) plot Methods: Data analysis
  6. 6. Results MEDLINE and EMBASE search (1995-2009) resulted in 3199 citations 22 authors did not share data despite an expressed intention to do so 3 of these were no longer available 2 had not been given institutional review board approval for data sharing 176 study reports deemed eligible (111 corresponding authors) 27 authors shared their datasets of 30 studies 107 authors were contacted 49 (46%) replied that they were interested in the project and willing to share data Eight studies (including 6708 unselected nulliparous women, of whom 302 (4.5%) developed PE) used in analysis as these had data on nulliparous women with 2nd trimester UtAD
  7. 7. • Mean PI performed better than lower and higher PI (although this was not statistically significant) • Mean RI performed significantly better than lower RI but not significantly better than higher RI • The addition of bilateral notching to models with mean PI alone or mean RI alone significantly improved model fit • The predictive models using mean PI either alone or in combination with bilateral notching performed slightly better than the models with using mean RI, though not significantly Results: Selection of Doppler ultrasound predictors
  8. 8. The discriminative ability of the models including both patient characteristics and Doppler parameters was significantly better than either in isolation Results: Added value of Doppler ultrasound measurements to patient characteristics Systolic BP Mean PI and bilateral notching Systolic BP + mean PI + bilateral notching AUC (95% CI) 0.64 (0.45–0.84) 0.75 (0.55–0.95) 0.85 (0.67–1.00) BMI mean PI and bilateral notching BMI + mean PI + bilateral notching AUC (95% CI) 0.64 (0.59–0.69) 0.67 (0.61–0.73) 0.73 (0.68–0.79) BMI + systolic BP mean PI and bilateral notching BMI + systolic BP + mean PI + bilateral notching AUC (95% CI) 0.65 (0.45–0.84) 0.75 (0.56–0.95) 0.85 (0.67–1.00) The results for all models involving mean RI were similar to those involving mean PI
  9. 9. The model with BMI, mean RI and bilateral notching showed good calibration. Women in the two deciles with highest calculated probabilities of pre-eclampsia can be easily distinguished from women with lower probabilities Results: Added value of Doppler ultrasound measurements to patient characteristics
  10. 10. The discriminative ability of the models predicting pre-eclampsia requiring delivery before 34 weeks was significantly improved by adding Doppler parameters to models including only patient characteristics (BMI) Results: Prediction of pre-eclampsia requiring delivery before 34 weeks BMI BMI + mean RI and bilateral notching P value AUC (95% CI) 0.66 (0.57–0.76) 0.92 (0.87–0.98) <0.001 BMI BMI + mean PI and bilateral notching P value AUC (95% CI) 0.62 (0.48–0.75) 0.95 (0.92–0.98) <0.001
  11. 11. Women ranked in the highest centiles of predicted probabilities from both models delivered earlier than women with lower probabilities of pre-eclampsia Results: Time to delivery, Survival curves BMI + mean UtA RI + bilateral notching Systolic BP + mean UtA PI + bilateral notching Survival curves showing time to delivery in women grouped by percentiles (p) of predicted risk for pre-eclampsia in two predictive models; ––––, ≤p75; ------, >p75–p80; ───,>p80– p85; ------, >p85–p90; ─── , >p90–p95; ------,>p95
  12. 12. Discussion • In nulliparous women, the combination of Doppler ultrasound parameters and bilateral notching significantly improves the prediction of pre-eclampsia based on the patient characteristics BMI and systolic blood pressure • Women at higher risk of pre-eclampsia (>10–15%) can be well differentiated from women with lower risks • Women with the highest calculated risk of pre-eclamspia deliver earlier than women at lower risk • The methodology of IPD meta-analysis has several advantages over conventional meta-analysis, including the ability to use all available data from a study, including unpublished data, superior quality checks and better interpretation of the results
  13. 13. Limitations • As all studies included were primarily designed to investigate uterine artery Doppler, the number and type of patient characteristics differed between studies. This led to the investigation of only a limited number of patient characteristics Future perspectives • The results of the present meta-analysis should be externally validated in another large dataset • Further research investigating the effectiveness of a screen- and-treat strategy in the second trimester is needed
  14. 14. Discussion points • How can the results of this meta-analysis be applied in clinical practice? • In the light of the present meta-analysis, should all women be offered second-trimester uterine artery Doppler? • How should nulliparous low-risk women with abnormal second-trimester uterine artery Doppler be counselled and managed? • Is there an effective intervention to reduce the risk of pre-eclampsia in high risk women identified in the second trimester? Value of adding second-trimester uterine artery Doppler to patient characteristics in identification of nulliparous women at increased risk for pre- eclampsia: an individual patient data meta-analysis Kleinrouweler et al., UOG 2013

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