FIRST-TRIMESTER SCREENING & PREVENTION OF PET FIGO, 2019

FIRST-TRIMESTER SCREENING &
PREVENTION OF PET
FIGO, 2019
A pragmatic guide
Prof. Aboubakr Elnashar
Benha university, Egypt
ABOUBAKR MOHAMED ELNASHAR

‫البرجماتيه‬
‫العملي‬ ‫المذهب‬
‫العمالنيه‬
‫للحقيقه‬ ‫الوحيد‬ ‫المعيار‬ ‫العمل‬ ‫نجاح‬
‫التطبيق‬ ‫عبر‬ ‫استخراجها‬ ‫يتم‬ ‫النظريه‬
‫الذرائع‬ ‫فلسفه‬

CONTENTS
I. INTRODUCTION
1.Incidence
2.Definition
3.Classification
II. FIRST TRIMESTER PREDICTION
III. FIRST TRIMESTER PREVENTION
 CONCLUSION
3

I. INTRODUCTION
1. INCIDENCE
 2%–5% of pregnant women

2. DEFINITION
 Previous:
 onset of hypertension accompanied by significant
proteinuria after 20 weeks of gestation.

International Society for the Study of Hypertension in
Pregnancy (ISSHP).2018
 Hypertension
 SBP at ≥140 mm Hg &/or DBP at ≥90 mm Hg
 on at least two occasions measured 4 hours apart in
previously normotensive women
 accompanied by one or more of the following new-
onset conditions at or after 20 w:
1. Proteinuria
2. Maternal organ dysfunction
3. Uteroplacental dysfunction

1. Proteinuria
 ≥30 mg/mol protein:creatinine ratio
 ≥300 mg/24 h; or
 ≥2 + dipstick

2. Maternal organ dysfunction
 Acute kidney injury
(creatinine ≥90 μmol/L; 1 mg/dL)
 Liver involvement
(elevated transaminases, e.g. alanine aminotransferase or aspartate
aminotransferase >40 IU/L) with or without right upper quadrant or
epigastric abdominal pain;
 Neurological complications
(eclampsia, altered mental status, blindness, stroke, clonus, severe
headaches, and persistent visual scotomata); or
 Hematological complications
(thrombocytopenia–platelet count <150 000/μL, DIC, hemolysis); orABOUBAKR MOHAMED ELNASHAR

3. Uteroplacental dysfunction
 Fetal growth restriction
 Abnormal umbilical artery Doppler, or
 Stillbirth

 ACOG, 2013, 2015
 Syndrome of new onset of Hypertension
and either
Proteinuria or
End organ dysfunction
after 20 w in a previously normotensive woman

3. CLASSIFICATION
According to onset
*higher risk of short&long-term maternal& perinatal
morbidity&mortality.
(Lisonkova et al, 2014)
Preterm
Term
<34 w 34-37 w ≥37 w
Early* Preterm Term
Preterm Term

II. FIRST TRIMESTER PREDICTION OF PRETERM
PREECLAMPSIA
 Problems with existing methods of screening
 identify risk factors from maternal demographic
characteristics& medical history (maternal risk
factors).

 NICE:
 women should be considered to be at high risk of
developing PE if they have
 any one high-risk factor
 hypertensive disease in previous pregnancy
 chronic hypertension
 chronic renal disease
 DM
 autoimmune disease or
 any two moderate-risk factors
 nulliparity
 age ≥40 y
 BMI ≥35 kg/m2,
 family history of PE, or
 interpregnancy interval >10 y

 ACOG
women with a history of
 early-onset PE
 preterm delivery ≤34 w,
 ≥one prior pregnancy complicated by PE

 US Preventive Services Task Force guideline has now been
endorsed by ACOG, SMFM, and the American Diabetes
Association.
 One or more of history of
 PE,
 renal disease,
 Autoimmune disease
 type 1 or type 2 diabetes
 chronic hypertension or
 More than one of several moderate-risk factors
 first pregnancy
 age of ≥35 years
 BMI >30 kg/m2
 family history of PE
 sociodemographic characteristics, and personal history
factors

 Criticism:
1. Each risk factor as a separate screening test with additive
detection rate& screen-positive rate.
2. Maternal risk factors is not a sufficient tool for the
effective prediction of PE.
Guidelines
Detection rate of
False+ve
Preterm PE Term PE
NICE 39% 34% 10%
US preventive TF 90% 89% 64%

1. Risk Factors:
 Maternal
 Age, y
 Maternal weight, kg
 Maternal height, cm
 Maternal ethnicity: white, Afro-Caribbean, South Asian, East Asian, Mixed
 Obstetric
 Nulliparous, parous without prior PE, parous with prior PE
 Interpregnancy interval in years between the birth of the last child
 Gest age at delivery
 birth weight of previous pregnancy beyond 24 w
 Medical:
 Family history of PE (mother)
 Method of conception: spontaneous, ov induction, IVF
 Smoking habit
 History of chronic hypertension
 History of DM: type 1, type 2, insulin intake
 History of SLE or antiphospholipid syndromeABOUBAKR MOHAMED ELNASHAR

2. Measurement Of Blood Pressure
 measured by validated automated&semiautomated devices
 The measured sBP and dBP will be automatically
converted to MAP by the risk calculator.
 MAP=dBP+(sBP−dBP)∕3
 MAP
 is converted to a multiple of median (MoM),
adjusting for these associated maternal
characteristics& gestational age
 will be used for calculation of patient-specific
risk.

3. Measurement Of Uterine Artery Pulsatility Index
 TA US:
 done at 11+0 to 13+6 w
 corresponding to CRL 42–84 mm
 Gest age determined from measurement CRL.
 UTPI
 Abnormal if ≥90th percentile
 Is adjusted for associated maternal
characteristics& gest age by converting it to a
MoM

Identification of the uterine artery at the level of the internal os
(left) and typical waveforms of the uterine artery Doppler in the
first trimester of pregnancy.

4. Measurement Of Biochemical Markers
 PLGF.
 The best biochemical marker
 PAPP-A
 if measurements of PLGF& UTPI are not
available.

5. Combined Risk Assessment
 Patient-specific risk for preterm PE
 is calculated using the Bayes-based method.
 The risk calculator
 available free of charge on
 the webpage https://fetalmedicine
 FMF mobile app.
 medical records software.

 If Calculated risk: ≥1 in 100
 A woman is at high risk
 The first-trimester combined test
 most predictive of preterm PE but not term PE.
 The best model is the one that combines
1. Risk factors
2. MAP
3. UTPI.
4. PLGF

 Where it is not possible to measure the biochemical
markers and/or UTPI, the baseline screening test
should be a combination of
 Maternal risk factors with
 MAP & not maternal risk factors alone.

 Where
resources are
limited:
Two-stage screening
strategy
R factors+
MAP
UTPI+
PLGF

 Multiple pregnancies
 The same first-trimester combined test for PE in
singleton pregnancies can be adapted for
screening in twin pregnancies.
 It leads to the detection of nearly all affected cases
of PE but at a high screen-positive rate.

III. FIRST TRIMESTER PREVENTION OF PRETERM
PRE- ECLAMPSIA
 Women at high risk should receive aspirin prophylaxis
 Start at 11–14+6 w
 Dose: ~150 mg
minimum: 100mg/d
 Every night
 Stop:
 36 w, when delivery occurs, or
PE is diagnosed.

 In women with low calcium intake (<800 mg/d), either
 calcium replacement (≤1 g elemental calcium/d) or
 calcium supplementation (1.5–2 g elemental
calcium/d) may reduce the burden of both
early&late-onset PE.

 The benefit of other treatments, such as
 Heparin
 Vit C& E
 Magnesium
 Folate
 Metformin, and
 Statin for prophylaxis of preterm PE
 not yet based on credible evidence
 their use solely is neither justified nor
recommended.

CONCLUSION
For preterm pre-eclampsia screening& prevention.

You can get this lecture and 440 lecture from
1.My scientific page on Face book: Aboubakr
Elnashar Lectures.
https://www.facebook.com/groups/2277448840
91351/
2.Slide share web site
3. elnashar53@hotmail.com
4.My clinic: Althwara st, Mansura, Egypt

FIRST-TRIMESTER SCREENING & PREVENTION OF PET FIGO, 2019

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FIRST-TRIMESTER SCREENING & PREVENTION OF PET FIGO, 2019