state of the art of first trimester pre-eclampsia

The Fetal Medicine

Foundation

Prof Fabricio Costa MD, PhD, FRANZCOG, COGU,

Diploma in Fetal Medicine (FMF-London, UK)

Department of Gynecology and Obstetrics

University of São Paulo at Ribeirão Preto

Brazil

State of the art of first trimester

pre-eclampsia screening

DISCLAIMER

Copying, distribution and any kind of use require the written consent of the author.

Downloads and copies of the presentation are only permitted for private, non-commercial use.

The Fetal Medicine

Foundation

Why am I here?

The Fetal Medicine

Foundation

The Fetal Medicine

Foundation

- Identifying women at high risk in the first trimester allows preventive

actions such as low-dose aspirin intake starting before 16 weeks

- However, the number of women attending their first antenatal visit after

14 weeks is often more than 50% and can be as high as 88.5% in

developing countries

- Screening for PE in the second trimester could still be of benefit, since

close monitoring looking for early signs of PE allows timely treatment

and delivery

MUFW & SUFW

Who we are

Mid-2013

6 sites 10 sites

40,000 1st trim PE screenings

Largest dedicated O&G ultrasound practice in Australasia

~ 80,000 scans per year; 10,000 NIPT; 10,000 PE screenings

The Fetal Medicine

Foundation

We have a problem….

The Fetal Medicine

Foundation

2 - 8% of the pregnancies

6.6 million cases per year worldwide

US - 18% of maternal deaths

1 maternal death caused by PE every 12 minutes

15% of premature deliveries

Future cardiovascular risk

Pre-eclampsia

Background

Duley L. The global impact of pre-eclampsia and eclampsia. Semin Perinatol 2009; 33: 130-137.

Wu P et al. Circ Cardiovasc Qual Outcomes 2017; 10.

The Fetal Medicine

Foundation

The Fetal Medicine

Foundation

Mortality

Morbidity

The Fetal Medicine

Foundation

How are we addressing

this problem?

The Fetal Medicine

Foundation

Ministry of Health Report. 1929

Memorandum on antenatal clinics: their

conduct and scope. His Majesty’s Stationery

Office, London; 1930.

The Fetal Medicine

FoundationJAMA April 25, 2017 Volume 317, Number 16

The Fetal Medicine

Foundation Obstetricians in action…

The Fetal Medicine

FoundationClinical Chemistry 58:5 837–845 (2012)

The Fetal Medicine

Foundation

The Fetal Medicine

Foundation

Screening strategies

The Fetal Medicine

Foundation

High risk factors

Hypertensive disease in a previous pregnancy

Chronic renal disease

Chronic hypertension

Diabetes mellitus

Autoimmune disease such as SLE or APS

Moderate risk factors

First pregnancy

Age > 40 years

Body mass index > 35 kg/m2

Inter-pregnancy interval > 10 years

Family history of preeclampsia

NICE guidelines 2010

High-risk in need of aspirin

Preeclampsia in >2 previous pregnancies

Preeclampsia <34w in previous pregnancy

Task Force on Hypertension in Pregnancy

ACOG 2013

Risk factors

Preeclampsia in a previous pregnancy



Diabetes mellitus

SLE or thrombophilia

First pregnancy

Age > 40 years


Conception by in vitro fertilization


Prediction of pre-eclampsia

Guidelines

The Fetal Medicine

Foundation

Tan MY et al. Comparison of diagnostic accuracy of early screening for pre-eclampsia by NICE guidelines and a method combining

maternal factors and biomarkers: results of SPREE. Ultrasound Obstet Gynecol 2018, DOI 10.1002/uog.19039.

23%

High-risk x prevention – Nice, UK

0

10

20

30

40

50

60

80

90

100

70

Dete

cti

on

ra

te (

%)

<37w >37w Total

FP 10.2%

41%

26%30%


SPREE study, n=16,747

The Fetal Medicine

Foundation

10 %

High-risk x prevention


History-based screening

Ortved D, Hawkins TL, Johnson JA, et al. The cost-effectiveness of first trimester

screening and early preventative use of aspirin in women at high risk of early

onset pre-eclampsia. Ultrasound Obstet Gynecol 2018

24%

Australia – SOMANZ guidelines Canada – SOGC guidelines

Helou A et al. Management of pregnancies complicated by hypertensive

disorders of pregnancy: Could we do better? Aust N Z J Obstet Gynaecol

2017

The Fetal Medicine

Foundation Maternal mortality in Brazil

The Fetal Medicine

Foundation

The new approach

The Fetal Medicine

FoundationDisease Models & Mechanisms 2012 5: 9-18

The Fetal Medicine

Foundation

Early-onset PE is the worst

spectrum of the disease!

PRE-ECLAMPSIA

TWO DIFFERENT

SPECTRUM

PRETERM

DELIVERY < 37 WEEKS

TERM

DELIVERY > 37 WEEKS

30% OF CASES

80% 0F

COMPLICATIONS

70% OF CASES

20% OF

COMPLICATIONS

The Fetal Medicine

Foundation

Prevention of pre-eclampsia

Mechanism of disease

But is it really the placenta ? Or is it all about the heart ?

- Poor placentation

- Damage to endothelium and cardiovascular

system are secondary

- Aspirin is anti-inflammatory

- Bad heart

- Failure to reach fetal and placental demands

- Parallel with GDM, resolves with delivery

- Aspirin for prevention of cardiovascular disease

+

Preterm PE Term PE

37 weeks

The Fetal Medicine

Foundation

The Fetal Medicine

Foundation

Determine prior risk:• Maternal characteristics• Medical / obstetric history

Estimate posterior risk

• Measure biomarkers• Express as MoMs• Modify prior risk


New approach

The Fetal Medicine

Foundation

Effect on time to delivery with PE (w)

-8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4

Chronic Hypertension

Race Black

South Asian

SLE / APS

Family history of PE

Diabetes mellitus

Conception by IVF

Age 35 y

40 y

45 y

Weight 50 kg

70 kg

90 kg

110 kg

Wright D et al. Competing risks model in screening for preeclampsia by

maternal characteristics and medical history. Am J Obstet Gynecol 2015

Low risk

24 28 32 36 40 44 48 52 56 60 64 68 72 76 80

Gestational age at delivery with preeclampsia (w)

High risk

1%

30%

2-3%

24 28 32 36 40 44 48 52 56 60 64 68 72 76 80

Average risk


Maternal characteristics, n=120,492

The Fetal Medicine

Foundation

Gestational age (w)

24 28 32 36 40 44

0.05

0.1

0.2

0.30.40.5

1.0

1.52.0

3.44.45.0

Gestational age (w)

24 28 32 36 40 44

0.05

0.10.1

0.2

0.3

0.40.5

1.0

1.5

2.0

3.0

4.0

Gestational age (w)

24 28 32 36 40 44

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

1.6

0.3

0.4

0.5

0.6

0.8

1.0

1.5

2.0

2.5

3.03.54.0

Gestational age (w)

24 28 32 36 40 44

PLGF (MoM)PAPP-A (MoM)MAP (MoM)UTPI (MoM)

O’ Gorman N et al. Competing risks model in screening for preeclampsia by maternal factors and biomarkers at 11-13 weeks’ gestation. Am J Obstet Gynecol 2016

FPR 10%


Biomarkers, n=33,840

The Fetal Medicine

Foundation

• Age: every 10 years above 30 y• Weight: every 10 kg above 70 kg

• Racial origin Afro-CaribbeanSouth Asian

• Obstetric history First pregnancy

• Family history of preeclampsia

• Autoimmune : SLE / APS

• Chronic hypertension• Diabetes mellitus

Previous preeclampsia

• Conception by IVF

Maternal risk factors

Wright D et al. Competing risks model in screening for preeclampsia by maternal characteristics and medical

history. Am J Obstet Gynecol 2016;

O’Gorman N et al. Competing risks model in screening for preeclampsia by maternal factors and biomarkers

at 11-13 weeks’ gestation. Am J Obstet Gynecol 2016; 214: 103

0

10

20

30

40

50

60

80

90

100

70

PE <32w

De

tec

tio

n

rate

(%

)

FPR 10%

PE <37w PE >37w

History, MAP, UT PI, PLGF

75%

89%

47%


FMF algorithm – Bayes theorem

The Fetal Medicine

Foundation

High risk factors

Hypertensive disease in a previous pregnancy



Diabetes mellitus

Autoimmune disease such as SLE or APS

Moderate risk factors

First pregnancy

Age > 40 years


Inter-pregnancy interval > 10 years


NICE guidelines 2010

0

10

20

30

40

50

60

80

90

100

70

PE <37w

De

tec

tio

n ra

te (

%)

FMF: FPR 10.0%

NICE: FPR 10.3%

ACOG: FPR 0.2%

PE >37w

39%34%

75%

45%

ACOG 2013: High-risk in need of aspirin

Preeclampsia in >2 previous pregnancies

Preeclampsia <34w in previous pregnancy

5%2%

Prediction of preeclampsia

ASPRE screening validation

O'Gorman N et al. Multicenter screening for pre-eclampsia by maternal factors and biomarkers at

11-13 weeks' gestation: comparison with NICE guidelines and ACOG recommendations.

Ultrasound Obstet Gynecol 2017.

O'Gorman N et al. Accuracy of competing-risks model in screening for pre-eclampsia by maternal

factors and biomarkers at 11-13 weeks' gestation. Ultrasound Obstet Gynecol 2017.


ASPRE screening study, n=8,775

The Fetal Medicine

Foundation

PE 239 (2.7%)

8,775 underwent screening

No PE 8,536 (97.3%)

Virgen de la Arrixaca, Murcia, Spain

San Cecilio Hospital, Granada, Spain

Hospiten Sur, Tenerife, Spain

Chu Brugmann Brussels, Belgium

Attikon University Hospital, Greece

Ospedale Maggiore Policlinico, Italy

Rabin Medical Center, Israel

King’s College Hospital, UK

Medway Maritime Hospital, UK

Lewisham University Hospital, UK

North Middlesex Hospital, UK

Southend University Hospital, UK

Homerton University Hospital, UK

Statistical analysis: D Wright, A Wright PE <34 wD

ete

cti

on

rate

(%

)20

30

40

50

60

70

80

90

100

PE <37 w PE >37 w


ASPRE screening validation

The Fetal Medicine

Foundation History repeats itself...

PE screeningPatient

acceptability

Efficacy

Safety

Cost

The skepticism The fear of the unknown

The Fetal Medicine

Foundation

External validation

The Fetal Medicine

Foundation

Prof Jon Hyett

Sample 3066

The Fetal Medicine

Foundation

First trimester screening for early and late preeclampsia based on

maternal characteristics, biophysical parameters and

angiogenic factors.

Francesca Crovetto, MD; Francesc Figueras, MD; Stefania Triunfo, MD; Fatima Crispi, MD; Victor

Rodriguez-Sureda, PhD; Carmen Dominguez, PhD; Elisa Llurba, MD; Eduard Gratacos, MD.

Prenatal Diagnosis, Oct 2014

The Fetal Medicine

Foundation

The Fetal Medicine

Foundation


SPREE study

SCREENING METHOD <34w <37w >37w

NICE 47 41 26

History 48 42 30

MAP 65 49 40

UTPI 73 63 33

PLGF 67 59 34

PAPP-A 57 46 30

PLGF, PAPP-A 70 62 35

MAP, UTPI 88 74 44

MAP, PLGF 73 69 40

MAP, PAPP-A 67 54 38

MAP, UTPI, PLGF 90 82 44

MAP, UTPI, PAPP-A 87 77 43

MAP, PLGF, PAPP-A 78 69 39

MAP, UTPI, PLGF, PAPP-A 90 82 44

0

10

20

30

40

50

60

80

90

100

70

Dete

cti

on

ra

te (

%)

<34w

47%

90%

<37w

41%

82%

>37w

26%

44%

NICE

History, MAP, UTPI, PLGF

Tan MY, et al. Submitted 2018

The Fetal Medicine

Foundation

It’s complicated…

The Fetal Medicine

Foundation

Multiparametric

approach

The Fetal Medicine

Foundation


Risk calculation

The Fetal Medicine

Foundation


Risk calculation

www.fetalmedicine.org

The Fetal Medicine

Foundation


Risk calculation

Cell phone

app

The Fetal Medicine

Foundation

Quality assurance

The Fetal Medicine

Foundation

SUFW MUFW

0.9594: 95% CI 0.9583, 0.9605

Quality assurance - MAP

0.9737 : 95% CI 0.9717 , 0.9756

The Fetal Medicine

Foundation

1.0311 : 95% CI 1.0275 , 1.0346

SUFW MUFWQuality assurance – UtArt PI

1.0364 : 95% CI 1.0299 , 1.0429

The Fetal Medicine

Foundation

Screening of preeclampsia

Our research

Uterine artery DopplerQuality assurance

The Fetal Medicine

Foundation

1.137 : 95% CI 1.1296 , 1.1444

SUFW MUFW

Quality assurance – PAPP-A

1.0229 : 95% CI 1.0113 , 1.0346

The Fetal Medicine

Foundation

0.9776 : 95% CI 0.973 , 0.9823

SUFW

Quality assurance – PlGF

The Fetal Medicine

Foundation


SPR

SUFW

MUFW

~11%

~11%

ASPRE ~11%

The Fetal Medicine

Foundation

Global implementation

The Fetal Medicine

Foundation

J. Perinat. Med. 2017

Rocha RS, Alves JAG, Maia E Holanda Moura SB, Araujo Júnior E, Peixoto AB, Santana EFM, Martins WP, Vasconcelos CTM, Da Silva Costa F, Oriá

MOB. J Perinat Med. 2017 Oct 26;45(7):843-849.

The Fetal Medicine

Foundation

Rocha RS, Gurgel Alves JA, Bezerra Maia E Holanda Moura S, Araujo Júnior E, Martins WP, Vasconcelos CTM, Da Silva Costa F, Oriá MOB.

Pregnancy Hypertens. 2017 Oct;10:113-117.

The Fetal Medicine

Foundation

Stability of placental growth factor, soluble fms-

like tyrosine kinase 1, and soluble fms-like

tyrosine kinase 1 e15a in human serum and

plasma

S. Rowson1, M. Reddy2,3, D. L. Rolnik2,3, F. da

Silva Costa2,4, K.R. Palmer2,3.

Unpublished, 2019

The Fetal Medicine

Foundation

The Fetal Medicine

Foundation

“A combination of maternal factors,

maternal arterial blood pressure, uterine

artery Doppler and PlGF level at 11–13

weeks appears to be the most efficient

screening model for identification of

women at risk of PE” (GRADE OF

RECOMMENDATION: B).

Guideline

The Fetal Medicine

Foundation Upcoming FIGO guidelines

The Fetal Medicine

Foundation

Prevention

The Fetal Medicine

Foundation

Antiplatelet agents for prevention of pre-eclampsia: a meta-analysis of individual patient data

Askie LM, Duley L, Henderson-Smart DJ, Stewart LA. Lancet 2007; 369:1791

• Meta-analysis of individual patient data from 32,217 women, recruited to 31 randomised trials of PE prevention.

Antiplatelet agents vs. Control

• Relative risk of developing preeclampsia: 0.90 (95% CI 0.84-0.97)

• Relative risk of delivery before 34 weeks: 0.90 (95% CI 0.83-0.98)

• Relative risk of serious adverse outcome: 0.90 (95% CI 0.85-0.96)

• Antiplatelet agents had no significant effect on the risk of bleeding events for either the women or their babies

Moderate reduction in risk of PE, birth <34 weeks and serious adverse outcome


Low-dose aspirin

The Fetal Medicine

Foundation

Bujold et al., 2010; Roberge et al., 2012; 2013

.2 .4 .6 .8 1 1.2 1.6 2.00

Risk ratio (95% CI)

Preterm-PE(2/283 vs 43/273)

0.11 (0.04-0.3)

Term-PE(37/283 vs 32/273)

0.98 (0.4-2.3)

In the group with aspirin at <16 w

.2 .4 .6 .8 1 1.2 1.6 2.00

< 16 w (n=1,479) 0.47 (0.36-0.62)

> 16 w (n=10,673) 0.78 (0.61-0.99)

Gestation at start of aspirin


Low-dose aspirin

The Fetal Medicine

Foundation

Screening 26,941

High-risk 2,971

Randomised n=1,776

800 Aspirin 824 Placebo

Compliance:

86% of women took >80% of tablets

95% of women took >50% of tablets

Rolnik DL et al, Aspirin versus Placebo in Pregnancies at High Risk of Preterm Preeclampsia. NEJM 2017

11%

60%


ASPRE trial

The Fetal Medicine

Foundation

24 26 28 30 32 34 36 38 40 42

Gestation at delivery (wk)

Placebo

Aspirin

5

10

15

20

25

Cu

mu

lati

ve

in

cid

en

ce

of

PE

(%

)

0

PE <34 w: 1.8% vs 0.4% 82% drop

PE <37 w: 4.3% vs 1.6% 62% drop

PE >37 w: 7.2% vs 6.6% 5% drop

0

10

20

30

40

50

60

80

90

100

70

<34w

Pre

ven

tio

n ra

te (

%)

38%

18%

<37w

95%

>37w


ASPRE trial

Rolnik DL et al, Aspirin versus Placebo in Pregnancies at High Risk of Preterm Preeclampsia. NEJM 2017

The Fetal Medicine

Foundation

Poon LC, Rolnik DL, Tan MY, et al. Ultrasound Obstet Gynecol 2018

Incidence PE < 37w (0.7%)

FMF + FMF -

NICE + (10.8%) 6.9% 0.48%

ACOG + (64.5%) 4.8% 0.25%

Previous preeclampsia 708

(2.0%)

Preeclampsia < 37 w

35 (4.9%)

FMF –

2 (0.7%)

FMF +

33 (8.0 %)


ASPRE study, n=34,573

The Fetal Medicine

Foundation

Drug trials should take into account compliance

Aspirin vs. Placebo

0.05 0.2 1 1.50.1 0.5

OR with 95% CI

Compliance

0.38; 0.20 to 0.74

>90% (71%) 0.24; 0.09 to 0.65

Any (100%)

<90% (29%) 0.59; 0.23 to 1.53

Wright D, Poon LC, Rolnik DL, et al. Am J of Obstet Gynecol 2018


ASPRE trial - Compliance

The Fetal Medicine

Foundation

Prof Jon Hyett

Ultrasound in Obstetrics and Gynecology doi: 10.1002/uog.14819


The Fetal Medicine

Foundation

How does aspirin work?

Differentiation

PE

Apoptosis

PlGF

Cytokines

Shanika Panagodage,*y Hannah E.J. Yong,*y Fabricio Da Silva Costa,*y Anthony J.

Borg,* Bill Kalionis,*yShaun P. Brennecke,*y and Padma Murthi*yz

The American Journal of Pathology, Vol. 186, No. 12, December 2016

The Fetal Medicine

Foundation

“There is convincing evidence that low-

dose aspirin can decrease significantly

the risk for development of early PE, when

administration commences at the time of

first-trimester screening (GRADE OF

RECOMMENDATION: A).

Guideline

The Fetal Medicine

Foundation

Cost-effectiveness

The Fetal Medicine

Foundation

24 26 28 30 32 34 36 38 40 42

Gestation at birth (w)

0

5

10

15

20

25

30

35

40

45

50

55

Cu

mu

lati

ve n

um

ber

of

all b

ab

ies a

dm

itte

d t

o N

ICU

24 26 28 30 32 34 36 38 40 42


0

5

10

15

20

25

30

35

40

45

50

55

Cu

mu

lati

ve n

um

ber

of

bab

ies in

NIC

U f

or

>14 d

ays

24 26 28 30 32 34 36 38 40 42


0

100

200

300

400

500

600

700

800

900

1000

1100

1200

1300

1400

1500

1600

1700

Cu

mu

lati

ve len

gth

of

sta

y in

NIC

U (

days)

Wright D, Rolnik DL, Syngelaki A, et al. Am J Obstet Gynecol 2018


ASPRE trial - Lenght of stay in NICU

The Fetal Medicine

Foundation

Ortved D, Hawkins TL, Johnson JA, et al. The cost-effectiveness of first trimester screening and early preventative use of aspirin

in women at high risk of early onset pre-eclampsia. Ultrasound Obstet Gynecol 2018

Viguiliouk E, Park AL, Berger H, et al. Low rates of aspirin use for the prevention of preeclampsia. J Obstet Gynaecol Can 2017

Combined screening

Cost-effectiveness (Canada - n=387,516)

Current practice (SOGC) Cost $23,910,467.06

Cost $9,523,485.26

The cost-effectiveness of first trimester screening and early preventative use of

aspirin in women at high risk of early onset pre-eclampsia

Ortved D, Hawkins TL, Johnson JA, Hyett J, Metcalfe A, Ultrasound Obstet Gynecol, 2018


Cost-effectiveness

The Fetal Medicine

Foundation

Effective in low risk population?

Compliance / Adherence to treatment?

Long-term safety?


Universal aspirin ?

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Foundation

Strategy Detection Missed False positive Detected Cases avoided NNS NNT

FMF 77% 23% 10% 614 380 263 38

NICE 39% 61% 10.2% 312 193 517 55

ACOG 5% 95% 0.2% 40 25 4032 10

Universal Aspirin 100% – 99.2% - 496 No screening 202

800 PE < 37 weeks

Prevalence 0.8%

100,000 pregnancies


Clinical implementation

The Fetal Medicine

Foundation

Future perspectives

The Fetal Medicine

Foundation

Screening of pre-eclampsia

Our research

Chasing novel biomarkers to predict PE

The Fetal Medicine

Foundation

The Fetal Medicine

Foundation

BJOG. 2018 Jun;125(7):848-855

The Fetal Medicine

Foundation

Fetal fraction as a marker of placentation ? – potential marker


New markers

Rolnik DL, da Silva Costa F, Lee TJ, et al. Association between fetal fraction on cell-free DNA testing and first trimester markers for pre-eclampsia. Ultrasound Obstet Gynecol. 2018

The Fetal Medicine

Foundation

The cardiovascular toll of pre-eclampsia:

determining impacts on the maternal, fetal and placental vasculature

• Markers of endothelial dysfunction: sFlt-1, sFlt-1 e15a, PlGF, ICAM-1 and VCAM-1

• Markers of cardiovascular function:

- Uterine artery Doppler

- Ophthalmic artery Doppler

- Mean arterial pressure

- Cardiac output, stroke volume, heart rate, systemic vascular resistance

- Arterial stiffness

• Markers of fetal wellbeing

• Routine biochemical markers of pre-eclampsia

The Fetal Medicine

Foundation

ESPRESSO trial

NSW:

Jon Hyett

NHMRC Clinical Trials

Centre / William Tarnow-

Mordi

Victoria:

Fabricio Costa

Shaun Brennecke

Stephen Tong & Susan Walker

South Australia:

Gus Dekker

Jonathan Morris

Preeclampsia prevention trial –

1st trimester screening algorithm

Esomeprazole

The Fetal Medicine

Foundation

Esomeprazole for prevention of PET:

Phase II RCT

Primary outcome measure:

A 3mmHg reduction in maternal Mean Arterial Pressure

at 36 weeks.

Secondary outcome measures:

A reduction in serum [sFlt-1] or [sENG] at 34-36

weeks.

An increase in duration of pregnancy.

A reduction in the proportion of women developing pre-

eclampsia or gestational hypertension.

A reduction in levels of proteinuria at 34-36 weeks.

A significant difference in birth weight (mean | 3rd, 5th

and 10th centiles).

The Fetal Medicine

Foundation

Validação prospectiva do screening para pre-

eclampsia no primeiro trimestre da gestacao na

população brasileira SPREBRA study

Investigadores associados:

Prof Dr Ricardo Cavalli – FMRP/USP-SP

Prof Dr Geraldo Duarte – FMRP/USP-SP

Profa Dra Alessandra Marcolin – FMRP/USP-SP

Profa Dra Silvana Quintana – FMRP/USP-SP

Profa Dra Elaine Moisés – FMRP/USP-SP

Prof Dr Marcelo Zugaib – FMUSP-SP

Profa Dra Rossana Francisco – FMUSP-SP

Prof Dr Guilherme Lobo – UNIFESP-SP

Profa Dra Vera Borges – UNESP-SP

Profa Dra Denise Vaz Oliani – FAMERP-SP

Prof Dr Renato Sá – FIOCRUZ-RJ

Profa Dra Sammya Bezerra – UNIFOR-CE

Prof Dr Eduardo Fonseca – Universidade Federal da Paraíba-PB

Profa Dra Mônica Oriá – UFC-CE

Prof Dr Edson da Cunha Filho – PUC-RS

Dr Michael de Mello Constantino – FMPR-USP

Dr Daniel Rolnik – Monash University (Australia)

Investigador principal:

Prof Dr Fabricio da Silva Costa

Instituicao:

Departamento de Ginecologia e Obstetricia,

Faculdade de Medicina de Ribeirao Preto,

Universidade de São Paulo

The Fetal Medicine

Foundation

What we do…

The Fetal Medicine

Foundation


Our NEW model

NIPT+

1st trim morphology scan

10-11 w

12-13 w

NT

Maternal factors

MAP

UtArt PI

NIPT bloods β-hcg, PAPP-A, PlGF

FTCS β-hcg, PAPP-A, PlGF

US

The Fetal Medicine

Foundation


Take home messages

Current strategy using only maternal history is not effective

There is a strong body of evidence supporting combined screening

At least combination of maternal history and MAP. Full screening is ideal

(UtA and PlGF)

ISUOG guideline supports combined screening. FIGO guideline coming

soon

Aspirin prevents PE effectively in a truly high risk group

It’s time for clinical implementation!

The Fetal Medicine

Foundation

Thank you!

state of the art of first trimester pre-eclampsia

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