Determining the Role of Pregnancy-associated Plasma Protein-A Level in the First Trimester of Pregnancy and Clinical Outcome in an Urban Referral Centre, South India

Abstract

Introduction: The use of first trimester screening including nuchal translucency (NT), pregnancy-associated plasma protein-A (PAPP-A), free-beta subunit human chorionicgonadotrophin (f\(\beta\)hCG) to detect aneuploidy has become an integral part of prenatal care. Estimation of serum PAPP-A levels have also been studied extensively regarding other predictability for adverse perinatal outcome. This study which is a case control study also tries to establish the association between low PAPP-A levels among the pregnant woman and adverse maternal foetal outcome. Objectives: Primary Objective: To determine the association of low PAPP-A level in the first trimester of pregnancy with the adverse maternal and foetal outcomes. Secondary Objective: To estimate the predictive values of low PAPP-A level in predicting adverse perinatal outcomes. Methods: This is a case -control study done during August 2017-May 2018 in the women delivered at the Department of OBG at Mehta Multispecialty Hospitals India Pvt. Ltd. Women delivered in the labour room who had a first trimester screening of PAPP-A level.were explained about the study after getting informed consent (Annexure II & III), questionnaire which include detailed antenatal history, mode of delivery and details of the baby data, entered into the annexure II. Depending upon the outcome, the subjects are classified as case group or control group. Out of the study sample of 264 subjects, 88 patients who were reported to have complication were taken as cases and 176 patients with no complications are taken as control and both the case and control group study were undertaken. Results: The study had revealed that there is no statistically significant association of factors such as maternal age, parity, marital history, family history and previous obstetric complication between the case and control groups. Mode of conception (ART, IUI, Ovulation induction) than spontaneous conception, significantly represented more number in case group compared to control group which is proved statistically (p < 0.05). In case group, 78% had deliveries < 37 weeks and 18% had term deliveries and the difference was statistically significant with the control group In our study there is high incidence of PIH & Pre-Eclampsia (17%), followed by Preterm (9.1%) and IUGR (6.8%) with normal outcomes in 66.7%. In our study, out of 264 deliveries, LSCS rate is higher compared to the normal delivery. The percentage of normal delivery is 28%, while LSCS deliveries were more than 72%. In our study Low PAPP-A level (<0.5MoM) shows high incidence of PIH & Preeclampsia, followed by IUGR and Preterm. When PAPP-A level >0.5MoM, normal outcome is more than the adverse outcome. The difference in the PAPP-A levels is statistically significant. In women with low PAPP A level, low birth weight found statistically significant when compared with < 0.5 PAPP A level. NICU admission & APGAR not found to be statistically significant. LBW babies prevalent high in low PAPP A level. In the present study, the sensitivity of PAPP A levels in identifying the complicated outcomes was 17.04% and the specificity was 98.85%. The positive predictive value of predicting the complications was 88.23% and negative predictive value of 70.44%. Conclusion: Thus from the above study, it is as curtained that the low PAPP-A levels confirmed during first trimester of pregnancy is associated with adverse maternal and fetal outcome such as PIH, preeclampsia, preterm, IUGR & LBW. Hence the obstetrician should be alert and watchful whenever encountering patients with low PAPP-A levels which can also help on self to be prepared.