#Grand Rounds

Results from the SPREE Trial: How Does First Trimester Preeclampsia Screening Compare to Current Guidelines?

BACKGROUND AND PURPOSE:

Current NICE guidelines use maternal characteristics and medical history to identify women at high risk for preeclampsia (PE) who could benefit from aspirin
NICE guideline considers a pregnant woman at high risk if
- Any one major factor
  - History of hypertensive disease in previous pregnancy
  - Chronic kidney disease
  - Autoimmune disease
  - Diabetes mellitus
  - Chronic hypertension
- OR any two moderate factors
  - First pregnancy at age ≥ 40 years
  - Interpregnancy interval > 10 years
  - BMI at first visit ≥ 35 kg/m2
  - Family history of PE
- Using more traditional approach of professional committees, each factor is considered separately
- Tan et al. (Ultrasound in Obstetrics & Gynecology, 2018) compared the above NICE approach to screening PE to a method that uses Bayes’ theorem that combines maternal factors with biomarkers

Prospective multicenter cohort study
Screening program for pre-eclampsia (SPREE) study
Participants: Singleton pregnancies at 11–13 weeks’ gestation had recording of maternal characteristics and medical history and measurements of
- Mean arterial pressure (MAP)
- Uterine artery pulsatility index (UtA‐PI)
- Serum placental growth factor (PlGF)
- Serum pregnancy‐associated plasma protein‐A (PAPP‐A)
The performance of screening for PE by the Bayes’ theorem‐based method was compared with that of the NICE method
Primary outcome
- Detection rate (DR) using NICE method vs mini‐combined test (maternal factors, MAP and PAPP‐A) in the prediction of PE at any gestational age (all‐PE) for the same screen‐positive rate determined by the NICE method
Secondary comparisons
- DR of screening recommended by the NICE guidelines vs 3 Bayes’ theorem‐based methods for prediction of preterm PE (requiring delivery <37weeks)
  - Maternal factors, MAP and PAPP‐A
  - Maternal factors, MAP and PlGF
  - Maternal factors, MAP, UtA‐PI and PlGF

17,051 women were eligible and outcome data were obtained from 16,747
All-PE developed in 2.8% of the 16,747 pregnancies and preterm PE developed in 0.8%
NICE method for PE
- Screen positive rate: 10.3%
- DR for all‐PE: 30.4%
- DR for preterm PE: 40.8%
- There was only 23% compliance with aspirin recommendation
Mini-combined method for PE
- DR of the mini‐combined test for all‐PE was 42.5%
- Superior to that of the NICE method by 12.1% (95% CI, 7.9–16.2%)
Screening for preterm PE compared to NICE
- Maternal factors, MAP and PlGF: DR was 69.0%, which was superior to NICE method by 28.2% (95% CI, 19.4–37.0%)
- Maternal factors, MAP, UtA‐PI and PlGF: DR was 82.4%, which was to NICE method by 41.6% (95% CI, 33.2–49.9%)

NICE detection rates and compliance were lower than using a Bayesian approach that incorporates serum markers
The authors state that a PE methodology that combines biomarkers with maternal factors is a substantial improvement over current recommendations

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