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Grand Rounds

First Trimester Screening for Preeclampsia: Implementation Results from a Clinical Practice Setting

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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

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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

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