BACKGROUND AND PURPOSE:

• Guy et al. (BJOG, 2020) evaluated the clinical effectiveness of the Fetal Medicine Foundation (FMF) preeclampsia screening program when implemented in a public healthcare setting

METHODS:

• Retrospective cohort study
  • In March 2018, St George’s University Hospitals NHS Foundation Trust adopted first trimester screening for preeclampsia based on the ASPRE study
  • Prior to ASPRE, patients were screened using the National Institute for Health and Care Excellence (NICE) criteria based on clinical features
• Participants
  • Women screened for preeclampsia
• Exposures
  • NICE risk-based guidance for PE
  • FMF algorithm which combined
    • Maternal risk factors
    • Blood pressure (MAP)
    • PAPP-A
    • Uterine artery Doppler
• Study design
  • High risk was defined by
    • Standard NICE criteria in the pre-intervention cohort (see ‘Learn More – Primary Sources’) | Prescribed 75 mg aspirin
    • A risk of ≥1:50 for preterm PE from the FMF algorithm in the post-intervention cohort | Prescribed 150 mg aspirin
• Primary outcome
  • Screening effectiveness
  • Rates of preeclampsia

RESULTS:

• 12,561 women were included
  • Screened with NICE guidelines: 7720 women
  • Screened with FMF: 4841 women
• FMF screening led to a significant reduction in the screen-positive rate
  • NICE: 16.1%
  • FMF: 8.2%
  • Odds ratio (OR) 0.50 (95% CI, 0.41 to 0.53)
• FMF screening also led to increased targeted aspirin physician prescribing among high risk women
  • NICE: 28.9%
  • FMF: 99.0%
  • OR 241.6 (95% CI, 89.6 to 652.0)
• Receiver operating characteristic (ROC) analysis demonstrated good discrimination for preterm preeclampsia
  • Area under the curve (AUC) 0.846 (95% CI, 0.778 to 0.915; P <0.001)
• FMF screening was associated with a significant relative effect reduction (over 21 months) for
  • Preterm preeclampsia (<37 weeks): Reduction of 80% (P = 0.025)
  • Early preeclampsia (<34 weeks): Reduction of 89% (P = 0.017)

CONCLUSION:

• In a ‘real world’ setting, the use of FMF first-trimester combined screening for preeclampsia demonstrated reduction in positive screen rates, improved preterm preeclampsia detection and reduction in prevalence of preterm preeclampsia
• The authors state

Given the demonstration of efficacy of such a screening programme in an RCT and now a demonstration of its effectiveness in a public healthcare setting, the continued use of a risk factor‐based screening must be re‐evaluated

Learn More – Primary Sources:

Implementation of routine first trimester combined screening for pre‐eclampsia: a clinical effectiveness study

NICE: Hypertension in pregnancy: diagnosis and management

Related ObG Topics:

The FMF Model: Maternal Characteristics, Ultrasound and PlGF to Predict Preterm Preeclampsia

Consensus Statement: Screening for Early-Onset Preeclampsia and Aspirin Prophylaxis in the US

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

ASPRE Trial: A Combined Risk Algorithm and Use of Aspirin to Prevent Preterm Preeclampsia