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UltrasoundUltrasound markers markers of of prepre--eclampsiaeclampsia
G.MacéG.Macé, , E.CynoberE.Cynober, , B.CarbonneB.Carbonne
Hôpital SaintHôpital Saint--Antoine, ParisAntoine, Paris
PlacentalPlacental diseasedisease
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Abnormal trophoblastic invasionAbnormal trophoblastic invasion
EndothelialEndothelial activationactivation
AbnormalAbnormal trophoblastictrophoblasticinvasioninvasion
PlacentalPlacental ischemiaischemia
Vasoconstriction / microVasoconstriction / micro--thrombosesthromboses
majorationmajoration of ischemiaschemia
MaternalMaternal endothelialendothelial activation activation
IUGRIUGR abruptionabruption
PrePre--eclampsiaeclampsia HELLPHELLPsyndromesyndrome
stillbirthstillbirth
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UltrasoundUltrasound markersmarkers
•• UterineUterine DopplersDopplers
•• FetalFetal growthgrowth
•• FetalFetal DopplersDopplers•• FetalFetal DopplersDopplers
PI= S-D/m RI= S-D/S
S
D
/
S
D
or DI=D/S
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Insufficient colonization normal colonization
A A, C, D and B
B/A: Diastolic IndexA-B/A: Resistance Index
C DB
A-B/A: Resistance IndexA-B/m : Pulsatility Index
B
« The Notch »
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Notch 1 Notch 3
Notch 2 Notch 4
Severity
PlacentalPlacental sideside
2 2 arteriesarteries
IndexIndex
N+IndexN+Index
antiplacentalantiplacental sideside
1 1 arteryarteryNotchingNotching
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Technical aspects of measurement
Transabdominal Pseudo-crossing
TransvaginalUterine crossing
Transversal view
Para sagittal right UA Para sagittal left UA
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Slight changes: pathologic threshold
33% 46%
Factors altering the measurement
P th b• Pressure on the probe• Maternal hemodynamic fluctuations• Level of signal on the artery• Uterine contractions
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Abdominal pressure
D/S = 32% D/S = 48%
Factors influencing the notching
• Maternal heart rate• Maternal heart rate• Decreased speed: spread intervals
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AmplitudeChange probe axis: parallel to the artery
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Differential diagnosis
arcuate artery
Diagnosis of notching
• Adequate artery at the adequate level• Adequate artery at the adequate level• Significant if permanent• Increased RI frequently associated• Evolution during pregnancy
= Clinical impact= Clinical impact
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reference curves for PIfirst trimester, and until term
1,00
1,25
1,50
1,75
2,00
2,25
2,50
2,75
3,00
Chagnaud et al 2008 Gomes et al 2008
,50
,75
1,00
75 77 79 81 83 85 87 89 91 93 95 97 99
Evolution of notching
Gomes et al, 2008
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Choice of indices (Cnossen CMAJ 2008)Meta-analysis, 74 studies, n= 79547
Maternal risk factors for preeclampsia
African (LR+= 1.45)BMI ≥ 35 (LR+= 2.18)h i HTA (LR+ 12 52)chronic HTA (LR+= 12.52)
Personal history PE (LR+= 3.19)Nullipara (LR+= 1.23)Parity ≥ 2 (LR+= 1.72)
Papagiorghiou 2005
Define standard high risk population
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Maternal risk factors for preeclampsia
African (LR+= 1.45)BMI ≥ 35 (LR+= 2.18)h i HTA (LR+ 12 52)chronic HTA (LR+= 12.52)
Personal history PE (LR+= 3.19)Nullipara (LR+= 1.23)Parity ≥ 2 (LR+= 1.72)
Prediction of PE (FP fixed 25%)Prediction of PE (FP fixed 25%)
Maternal Characteristics = 45.3%Uterine artery Doppler = 63.1%Combination of both = 67.5%
Papagiorghiou 2005
T2 Doppler Screening
00 55 1010
PI + 1N+
2N+
RI + 1N+
00 55 1010
LR low risk second trimester (Cnossen 2008)
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Low risk T2 Doppler n=1580 (Papageorghiou 2005)
Prevalence 3-5%: For FP rate 5%, 50% PE identified
Identifies 30% Identifies 30% severesevere PE, PE, betterbetter afterafter 13 SA 13 SA
Early screening, low risk
Harrington et alHarrington et al
CnossenCnossen et alet al
Melchiorre et alMelchiorre et al
Martin et alMartin et al
LikelihoodLikelihood Ratio for Ratio for PrePre--eclampsiaeclampsia
00 55 1010
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Optimization of uterine artery Doppler, maternal history and evolution during pregnancy
Early and late PE, ROC curves. (Plasencia, UOG 2008)
PredictivePredictive value of value of NotchingNotching
in a in a highhigh--riskrisk population population (Bats 2002)(Bats 2002)
11st st trim.trim. 22dd trim.trim. 33dd trim.trim.
92 %92 % 91 %91 % 81 %81 %
50 %50 % 50 %50 % 40 %40 %
% % notchnotch
PPVPPV
NPVNPV
38 %38 % 19 %19 % 18 %18 %
75 %75 % 90 %90 % 85 %85 %
75 %75 % 50 %50 % 33 %33 %Sens.Sens.
SpecSpec..
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TreatmentTreatment: : AspirinAspirin ??RecurrenceRecurrence of of prepre--eclampsiaeclampsia Duley et al. BMJ 2001Duley et al. BMJ 2001
Prospective Randomised trials
Low-risk: Doppler at 20-24 SA, aspirin if pathologicControl group: No DopplerOutcome measure: prevalence of pre-eclampsia
cohortcohort
45604560
LR totalLR total
3.23.2Subtil et alSubtil et al
BJOG 2003BJOG 2003
InterventionIntervention
1.141.14
[0.7[0.7--1.4]1.4]
33173317 2.12.1GoffinetGoffinet et alet al
BJOG 2001BJOG 2001
1.021.02
[0.8[0.8--1.5]1.5]
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AspirinAspirin in a in a highhigh riskrisk population population duringduring first first trimestertrimester
VainioVainio et al 2002et al 2002
Selection on Bilateral notching at 12 weeksRandomised Control Study45 aspirin / 45 placebo30 controls without notching
AS (43) Placebo (43)AS (43) Placebo (43) RRRRHTA of pregnancy HTA of pregnancy 11,611,6 37,237,2 0,31(0,130,31(0,13--0,78)0,78)PEPE 4,74,7 23,323,3 0,20(0,050,20(0,05--0,86)0,86)IUGRIUGR 2,32,3 7 7 0,33(0,040,33(0,04--3,08)3,08)
• Bilateral notching T1 as screening test? – prevalence 55% (Martin et al)– Not randomised
• Clinical impact– Aspirin in identified groups leads to a decreasing of
mild proteinuric HTA– Lack of power considering severe PE
Clinical benefit to prove regarding difficult ultrasound practice to generalised
Comments on Vainio et al 2002
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low dose Aspirin in high risk population before 20 WG
Coomarasamy RCOG 2002
Strategy for PE prediction
Previous obstetrical history Second trimester UDPrevious obstetrical history Chronic HTA
Early Uterine artery doppler in low risk?
Second trimester UD
LR > 5, PPV > 50%NPV similar to low risk
Cnossen, 2008
Optimal surveillance but no treatment exists after 22WG
early UD in high risk / Biomarkers / algorythms ?
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Conclusion
• Uterin doppler is a « physiological » marker• Uterin doppler is a « physiological » marker• Effective tool if skilled operator• Time screening dilemna• No clinical benefit on RCT• Associated maternal factors optimization
Others predictive markers?