clinical predictors and biomarkers in preeclampsia: …€¦ · annual meeting 2016 montreal, qc...
TRANSCRIPT
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Canadian Society of Internal Medicine Annual Meeting 2016
Montreal, QC
CLINICAL PREDICTORS AND BIOMARKERS IN PREECLAMPSIA: WHAT
SHOULD WE TELL OUR PATIENTS?
Dr Evelyne Rey, Obstetric Medicine Division, CHU Sainte-Justine, University of Montreal
Montreal
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Canadian Society of Internal Medicine Annual Meeting 2016
Montreal, QC
Someofthedrugs,devices,ortreatmentmodalitiesmentionedinthispresentationare:aspirin
No Conflict Disclosures
E. Rey. CLINICAL PREDICTORS AND BIOMARKERS IN PREECLAMPSIA. 2016-10-29 2
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Canadian Society of Internal Medicine Annual Meeting 2016
Montreal, QC
The following presentation represents the views of the speakerat the time of the presentation. This information is meant for educational purposes, and should not replace other sources
of information or your medical judgment.
E. Rey. CLINICAL PREDICTORS AND BIOMARKERS IN PREECLAMPSIA. 2016-10-293
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CSIM2016
OBJECTIVES
• Identifyspecificelementsfrompastmedicalhistory,physicalexaminationandobstetrichistorythatcanhelppredictpreeclampsia
• Selectpatientsthatcanbenefitfromimagingtechniquestohelppredictpreeclampsia
• Recognizetheclinicalutilityofexistingorpromisingbiomarkersforpredictionofpreeclampsia(PE)
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CSIM2016
PLAN
• Physiology
• Predictors– Clinicalriskfactors
– Biomarkers
– Doppler
– Cell-freefetalDNA
– Podocyturia,Microalbuminuria
• Cases
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CSIM2016
PartialmaternaltoleranceofallogenictrophoblastStage1
Stage2
ModifiedfromRedmanCW2005
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CSIM2016 Adapted from Redman 20057
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CSIM2016
PartialmaternaltoleranceofallogenictrophoblastStage1
Stage2
Stage3
ModifiedfromRedmanCW2005
Sub-clinicalinflammation,genetics,behavioralfactors
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CSIM2016
PartialmaternaltoleranceofallogenictrophoblastStage1
Stage2
Stage3
Placentalmarkers
ModifiedfromRedmanCW2005
Sub-clinicalinflammation,genetics,Behavioralfactors
• ↓PP13• ↓PAPP-A• ↓ADAM12• ↓Metastin
• ↓β-hCG
• ↑Activin-A
• ↑Inhibin-A
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CSIM2016
PartialmaternaltoleranceofallogenictrophoblastStage1
Stage2
Stage3
Vascularmarkers
ModifiedfromRedmanCW2005
AngiogenicF.
↓VEGF↓PlGF
AntiAngiogenicF.↑sFlt-1 ↑sEndoglin
↑sFlt-1/PlGF
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CSIM2016
PartialmaternaltoleranceofallogenictrophoblastStage1
Stage2
Stage3
Imaging
ModifiedfromRedmanCW2005
11
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CSIM2016
PartialmaternaltoleranceofallogenictrophoblastStage1
Stage2
Stage3
ModifiedfromRedmanCW2005
PredictionProphylaxisPreventoccurrencePreventseverity
EarlydiagnosisPrognosisClosematernalandfetalfollow-up
Severityprediction,Transfer,Delivery
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CSIM2016
CLINICALRISKFACTORS
• Familyhistory
• Personalmedicalhistory
• Demographiccharacteristics
• Pregnancy-relatedfactors
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CSIM2016
MageeLASOGC2008
14
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CSIM2016 15
BartschE.BMJ2016
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CSIM2016
CLINICALRISKFACTORS
PredictorModelsMetaanalysisAL-RubaieZTAetalBJOG2016
ParityPreviousPEEthnicitycHTConceptionmethodMeanBP
EPESensitivity70%Specificity70%
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Poonetal.
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BLOODPRESSURE
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CSIM2016
UADOPPLERVELOCIMETRY1stT• Sensitivity48%,specificity92%• Notalone• NotdoneroutinelyinCanada
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When?AnytimeifIUGR19-20w• Ifabnormalbiomarkers:usefulness?• IfriskofIUGR
LausmanA.JOGC2013
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CSIM2016
BIOMARKERS
• Availability
• Aneuploidyscreening
– 1TPAPP-A
– 2T-hCG
–alphaFP–Estriol–Inhibin-A
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CSIM2016
BIOMARKERS
1stT/earlysecondtrimester
– PAPP-A– Inhibin-A–PlGF
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CSIM2016
Nicolaides2008
21
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EPE• Parity• PreviousPE• Ethnicity• cHT• Conception• MeanBP
LPE• +• FamilyHPE• Age• BMI
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CSIM2016
OlivieraNetal.UltrasoundObstetGynecol2014
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CSIM2016
EFFICACYOFTHEMODELS?
• NoRCT
• ASPRE
• CohortscomparisonParksetal2015
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CSIM2016
ParkFetal.UltrasundObstetGynecol2015;46:419
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CSIM2016
Cell-freeFETALDNA• Increaseswithmarkersofplacentasize• Markerfortrophoblasticcelldeath• YuH2013:Increasesat11-14winEPE:sensitivity90%specificity85%
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NEXTMARKER?
LevineRJAJOG2004
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CSIM2016
Medicaldictionnonary2011
28
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CSIM2016
MollerCCetal.JAmSocNephrol2009
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SCMI2016 30
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CSIM2016
Craicietal.Hypertension2013:1289-96
Lateentryinthestudy
PODOCYTURIA
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SCMI2016
MICROALBUMINURIA< 20wks
– Lowrisk:no
– cHtorpreviousPreeclampsia
• higherlevel• Laura-Gonzalez2003:20mg/l
–Sensitivity79%etspecificity63%
–PPV46%NPV88%
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CotéAMCurrentHypertensionreviews2010
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CSIM2016
MICROALBUMINURIAINDB
• StrongriskfactorforPE• JensenDMDiabCare2010:846womenT1DB
–NoMicroA:12%PEvs
–MicroA:40%PE
–MicroA:ORa4,nulliparityORa3
•CastiglioniMTPregnancyHyper2014– cHTOR17(3-91),MicroAOR3.8(1.2-11.6),1TGHcOR2.8(1.1-7)
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CSIM2016
Case1
• Kimberly,29y,G1P0,
• Essentialchronichypertension
• Blackrace
• BMI36
• 154/104at12w
35
Riskofpreeclampsia?.5-10%.10-20%.20-30%.>30%
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CSIM2016 36
BartschE.BMJ2016
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BramhamK.BMJ2014
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CSIM2016 39
Abnormalif< 0.4MoM
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CSIM2016
Case2
• Sandra,37y,G1,
• Type2DBx10y.Notsmoking
• Whiterace
• BMI44
• BP114/76at15w
40
Riskofpreeclampsia?
.5-10%
.10-20%
.20-30%
.>30%
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SCMI2016
OTHERINFORMATION?
GH
41
Sandra=7.9%
Microalbuminuria
Sandra=none
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CSIM2016
MICROALBUMINURIAINDB
• StrongriskfactorforPE• JensenDMDiabCare2010:846womenT1DB
–NoMicroA:12%PEvs
–MicroA:40%PE
–MicroA:ORa4,nulliparityORa3
• CastiglioniMTPregnancyHyper2014
– cHTOR17(3-91),MicroAOR3.8(1.2-11.6),1TGHcOR2.8(1.1-7)
42
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CSIM2016 43
Abnormalif< 0.4MoM
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CSIM2016
Case3
• Mandy,35y,G2P1
• PreviousEPE25w+IUGR.CS27w.
• Blackrace,BMI25
• BP130/80
44
Riskofpreeclampsia?
.10-20%
.20-30%
.30-40%
.>40%
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CSIM2016
OTHERINFORMATION?
• Placenta• Recurrence• Vascularmalperfusionlesionsassociatedwithrecurrence
WeinerE.PrenatalDiagnosis2015
45
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CSIM2016 46
Abnormalif< 0.4MoM
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SCMI2016
Preeclampsiarisk?
Dany Suzy
Age 22 29
BMI 30.2 24.8
Race White Black
BP12sem 120/50 120/80
PAPP-A 0.34 1.72
47
HypothyroïdismNonsmokingG1NoFHofPrE
ClinicalF. 4.8% 6.9%
+MAPANDPAPP-A
2.1% 7.3%
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SCMI2016
CONCLUSIONS
• HIGHRISKdefinedbyCLINICALFACTORS:REMAINMAJORTOOL
• Impactofbiomarkersonthisgroupofwomen?
• Biomarkersinmoderateriskwomenmoreuseful?
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CSIM2016 49
HAVEALOOK!GEMOQ.CA
JOINUSATtheNASOM/GEMOQmeeting
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CSIM2016 50
WithoutpreviousEPE
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SCMI2016 51
BartschE.BMJ2016