Reply

Abstract

We thank Professor Carbillon for his interest in our recently published study and his comments. We agree with his general statements regarding early-onset preeclampsia (EOPE) and its effect on perinatal death and severe morbidity. Consequently, there is a need for the development of effective EOPE screening and prevention. The components of the screening method, which was developed by the Fetal Medicine Foundation (FMF), include maternal factors, mean arterial pressure, pulsatility index in the uterine artery, and maternal serum markers.1Akolekar R. Syngelaki A. Poon L. et al.Competing risks model in early screening for preeclampsia by biophysical and biochemical markers.Fetal Diagn Ther. 2013; 33: 8-15Crossref PubMed Scopus (381) Google Scholar This algorithm has been shown to have a high detection rate (77%) for EOPE while maintaining a low false-positive rate (10%).1Akolekar R. Syngelaki A. Poon L. et al.Competing risks model in early screening for preeclampsia by biophysical and biochemical markers.Fetal Diagn Ther. 2013; 33: 8-15Crossref PubMed Scopus (381) Google Scholar Similar results were obtained in subsequent large studies.2O’Gorman N. Wright D. Syngelaki A. et al.Competing risks model in screening for preeclampsia by maternal factors and biomarkers at 11-13 weeks’ gestation.Am J Obstet Gynecol. 2016; 214: 103.e1-103.e12Abstract Full Text Full Text PDF PubMed Scopus (320) Google Scholar, 3O’Gorman N. Wright D. Poon L.C. et al.Accuracy of competing-risks model in screening for pre-eclampsia by maternal factors and biomarkers at 11-13 weeks’ gestation.Ultrasound Obstet Gynecol. 2017; 49: 751-755Crossref PubMed Scopus (155) Google Scholar In the recently published Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-Based Preeclampsia Prevention (ASPRE) trial, it was shown that administering low-dose aspirin (150 mg daily) to women who are identified by the FMF algorithm as being at an increased risk for preeclampsia reduced the incidence of EOPE (<34 weeks’ gestation) by approximately 82%.4Rolnik D.L. Wright D. Poon L.C. et al.Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia.N Engl J Med. 2017; 377: 613-622Crossref PubMed Scopus (1093) Google Scholar In our own study, we achieved 85% detection for EOPE at a 5% false-positive rate using the combination of maternal factors, mean arterial pressure, pulsatility index in the uterine artery, and maternal serum markers. Excluding maternal serum markers, we would have achieved a detection rate of 69% (77% at a 10% false-positive rate). We agree that maternal uterine pulsatility index is an important part of this screen and Professor Carbillon’s statements regarding the use of uterine artery pulsatility index in the second trimester are well taken. It does appear that midsecond-trimester Doppler of the maternal uterine arteries is highly effective as a screening method for EOPE either as an addition to first-trimester screening or in isolation.5Cnossen J.S. Morris R.K. ter Riet G. et al.Use of uterine artery Doppler ultrasonography to predict pre-eclampsia and intrauterine growth restriction: a systematic review and bivariable meta-analysis.Can Med Assoc J. 2008; 178: 701-711Crossref PubMed Scopus (523) Google Scholar However, the problem that was not stressed in Professor Carbillon’s letter is that starting low-dose aspirin prophylaxis at this point in gestation does not appear to be effective in preeclampsia prevention.6Bujold E. Roberge S. Lacasse Y. et al.Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early pregnancy: a meta-analysis.Obstet Gynecol. 2010; 116: 402-414Crossref PubMed Scopus (827) Google Scholar Therefore, from the standpoint of prevention of EOPE, only first-trimester screening meets criteria for an appropriate screening method for this condition. Our study demonstrates that high detection rate and low false-positive rate can be achieved in an unselected US population. The components, which we included in our screening protocol, are similar to the ones used in the FMF algorithm. However, it is likely that components used in screening for preeclampsia in various health care systems will be selected based on their availability and cost-effectiveness. High performance of maternal characteristics and assessment of uterine artery Doppler waveform for the prediction of early-onset preeclampsiaAmerican Journal of Obstetrics & GynecologyVol. 218Issue 5PreviewI read with great interest the recent article of Sonek et al, 1 who assessed the detection rate (DR) of first-trimester screening for early-onset preeclampsia (EOPE) at 11–13+6 weeks’ gestation using maternal characteristics, biochemical markers, and uterine artery Doppler (UAD). Full-Text PDF