update in prediction and early detection of pe

www.medicinafetalbarcelona.org/

Update in early detection and management of PE

Eduard Gratacos

www.medicinafetalbarcelona.org

http://www.medicinafetalbarcelona.org

http://www.medicinafetalbarcelona.org


Early and late PE

Prediction of late disease

Early detection with angiogenic factors

Update in management


Normal and abnormal placental implantation


Endothelial diseaseMOTHER

DAMAGE

DYSFUNCTION

HYPERSTIMULATION

EARLY-ONSET PE AND IUGRRelation between placental and maternal disease

Endothelial disease (poor implantation)

PLACENTA

HTA!

proteinuria

plateletshemolysisliverHELLP

eclampsia

IUGR

DPPNI

Fetal hypoxia

PRED

ISPO

SITI

ON

20 30 4025 35

www.fetalmedicinebarcelona.org/

EARLY-ONSET LATE-ONSET

PREECLAMPSIA

IUGR

PREECLAMPSIA + IUGR

1 %

1 %

4-8 %

4-8 %

http://www.fetalmedicinebarcelona.org



MATERNALPREDISPOSITION

ANOMALOUSPLACENTATION

PREECLAMPSIADisease of the vascular endothelium which requires

baseline hyperstimulation state (gestation)

+ maternal predisposition +/- additional insult (anomalous placentation)

Gestational Age


PE

20 30 4025 35

0

5

10

%

EARLY-ONSET PE (1%) LATE-ONSET PE (4-8%)

PROBLEM: MANAGEMENT PROBLEM: DIAGNOSIS

Degree plac. insufficiency: HIGH Degree plac. insufficiency: LOW

Maternal predisposition + Maternal predisposition +++

Prediction 1 trimester Prediction 2-3 T

34


EARLY(<34w)

LATE(>34w)

Maternal severe disease 83% 30%

Association IUGR 78% 15%

Abnormal Umbilical Artery Doppler 78% 43%

Abnormal Uterine Artery Doppler 95% 46%

Abnormal placental pathology +++ +

Sibai’06, Levine’06, Crispi’06, Egbor’06, Zhang’03, Sibai’03

PREECLAMPSIA: EARLY VERSUS LATE


Early and late PE


Early detection with angiogenic factors



Prediction of PE

PE

Detection Rates (for FPR 10%)

11-14w

LATE PE

25-65%EARLY PE

80-90%

INTEGRATED FIRST TRIMESTER APPROACHmaternal + UtA Doppler + biomarkers


UtA Doppler: Quan9ta9ve assessmentPulsa9lity index

0

1,0

2,0

3,0

4,0

10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42

Gómez O, Figueras F. Reference ranges for uterine artery mean pulsa9lity index at 11-‐41 weeks of gesta9on. Ultrasound Obstet Gynecol. 2008 Aug;32(2):128-‐32


A priori risk

A priori + Biophysical

with Angiogenic

Early(n=56)

First trimester screening

Crovetto et al, FDT, in press

DR 68% ! (5% FPR) DR 76%! (10% FPR)

A priori risk

A priori + Biophysical

with Angiogenic

DR 88% ! (5% FPR) DR 91%! (10% FPR)

Late(n=246)




Prediction of PE

PE

Detection Rates (for FPR 10%)

32-34w

LATE PE

70-75 %

Lai et al. Fetal Diagn Ther 2013(BP, UtA Doppler, sEng)

Chaiworapongsa et al. AJOG 2013(PlGF, sFlt-1, sEng)

THIRD TRIMESTER APPROACHmaternal OR UtA Doppler OR biomarkers


Early and late PE


Early detection (angiogenic factors)



Respecto a la proteinuria…

1. Solamente la proteinuria de 24 horas puede ser considerada un criterio diagnóstico

2. El ratio C/P es igual de sensible que la proteinuria de 24h3. La proteinuria cualitativa solamente tiene valor cuando es positiva

Caso clínico


Respecto a la proteinuria…

1. Solamente la proteinuria de 24 horas puede ser considerada un criterio diagnóstico

2. El ratio C/P es igual de sensible que la proteinuria de 24h3. La proteinuria cualitativa solamente tiene valor cuando es positiva

Caso clínico

El RCP debería desplazar la proteinuria cualitativa en casos de sospecha


pregnancy + hypertension: PE or gestational hypertension?

Ultrasounduterine artery / fetal Doppler

ClinicalBP

maternal historyBiomarkers

PlGF/sFlt-1/sEng/VCAM/othersClinical case

Pregnant women with HTA

5-10 % (750,000 / y Europe + America)

CURRENTLY:• identification at dx poor• strict follow up needed (large # exams)• misuse of resources

Integrated one-stepdiagnostic system

Clinical need: integrated one-step diagnostic system for placental disease



PREECLAMPSIA

Levine RJ. N Engl J Med. 2004

Screening•First trimester

PREDICTION

•Third trimester

PROGNOSIS

Early iden9fica9on in suspected pateints


PlGF<p5 in suspected PE (n=625)

Delivery due to PE <14 days

Chappell, Circulation, 2013

Sensitivity 96

0

20

40

60

80

100

<35 wn=287

35 to 36 wn=137

>37wn=201

70

57

%Screening test PE within 14d(patients<35w)

Blood pressure 0.67(0.05)

Urate 0.68 (0.06)

ALT 0.61 (0.05)

Dipstick Proteinuria 0.76 (0.04)

PlGF 0.87(0.03)

PlGF+BP+Urate+ALT 0.87 (0.03)


Early and late PE


Early detection (with angiogenic factors)



¿Como tratamos la preeclampsia leve?

•Reposo relativo y dieta normal

•Control diario Pródromos, TA (~80/130-105/155)

Peso

•Control analítica/15d y fetal/semanal

•Finalización a las 38+1 semanas(HYPITAT-I)


¿Cuándo finalizaremos la PE grave?

§>34.0

§>32.0.o si PIERS >5%

§Cualquier EG sí:

oTA refractaria a 2 fármacos

oPródromos eclampsia persistentes

oAfectación orgánica progresiva: renal, hepática, PLT

oComplicaciones maternas: EAP, DPPNI oIndicaciones fetales (=CIR)

Sí <32 semanas y Bishop<5: CS 85%

¿Como tratamos la preeclampsia grave?


PREECLAMPSIA

¿existen criterios de gravedad?

síno PREECLAMPSIA LEVE

TA>160/110proto >5g

GOT/GPT>70PLT<100000

LDH>700Edema pulmónCreatinina>1.5

Pródromos NRL

¿existe hemolisis y plaquetopenia y elevación GOT/GPT?

nosí

PREECLAMPSIA GRAVE

HELLP

ECLAMPSIA

¿ha convulsionado o está en coma?

nosí

H hemolisisEL elevated liver enzimsLP low platelets


PREECLAMPSIA

¿existen criterios de gravedad?

síno PREECLAMPSIA LEVE

TA>160/110proto >5g

GOT/GPT>70PLT<100000

LDH>700Edema pulmónCreatinina>1.5

Pródromos NRL

¿existe hemolisis y plaquetopenia y elevación GOT/GPT?

nosí

PREECLAMPSIA GRAVE

HELLP

ECLAMPSIA

¿ha convulsionado o está en coma?

nosí

H hemolisisEL elevated liver enzimsLP low platelets

Edat gestacional


Caso clínico


Early and late PE


Early detection (with angiogenic factors)


update in prediction and early detection of pe

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