[Show abstract][Hide abstract] ABSTRACT: Objective:
To validate a previously published prediction model for recurrent early-onset preeclampsia (PE).
We included 229 pregnant women with a history of early-onset PE and computed their risk using the prediction model, compared the predicted risk to their pregnancy outcomes and assessed performance of the model.
Early-onset PE recurred in 6.6% of participants. The area under the receiver operating characteristic curve was 59% (95% CI: 45-73). The model created groups that were only moderately different in terms of their risk.
The model's discriminate ability was poor and predictive performance insufficient to classify women into relevant risk groups.
Hypertension in Pregnancy 01/2014; 33(3). DOI:10.3109/10641955.2013.872253 · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Women who suffered from pregnancy complications are at increased risk for anxiety and depression. The aim of this study was to evaluate whether having suffered from preeclampsia (PE) or HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is associated with anxiety and depression, and whether PE/HELLP is an independent risk factor for developing anxiety and depression. Systematic search on PubMed and PsycInfo with no time limit. Studies presenting original data, including women with a history of PE/HELLP and at least one comparison group of women without PE/HELLP, reporting the results for each group separately or in a multivariate regression analysis with PE/HELLP as an independent variable. Study characteristics and outcomes were extracted using a prespecified form. If necessary, additional calculations were performed. The search yielded 267 articles, with only six being suitable for inclusion in this review. Studies on depression (six studies) showed generally positive associations between PE/HELLP and the prevalence of depression or severity of depressive symptoms. However, the results of three studies were not statistically significant. Studies addressing anxiety (two studies) did not show significant associations between PE/HELLP and anxiety scores. Associations between post‐traumatic stress and PE/HELLP, investigated in four studies, were often nonsignificant. Due to heterogeneity of study methods, a meta‐analysis of the results was not possible. In most studies, confounder control was poor. Evidence is mixed but generally points to positive associations between various forms of psychopathology and previous PE/HELLP. Causality of the associations can, however, not be judged adequately.
[Show abstract][Hide abstract] ABSTRACT: Women with a history of early-onset preeclampsia, requiring delivery before 34 weeks of gestation, often receive intensive surveillance with far more visits than routine antenatal care, additional testing such as the serial measurement of various fetal arterial Doppler blood flow velocity profiles, repetitive assessment of the fetal biometry, the amount of amniotic fluid, the fetal biophysical profile, and repetitive blood testing. Yet, recurrence risk is generally low.Objectives
To develop and validate a prepregnant prediction model to identify women at very low risk of recurrence of early-onset preeclampsia. These women may be reassured and offered routine antenatal care.Methods
For the derivation of the model, we enrolled 407 pregnant women from 5 Dutch hospitals who had experienced early-onset preeclampsia in their previous pregnancy. Based on previous published evidence, we selected five predictor variables (gestational age at the time of previous birth, prior small-for-gestational-age (SGA) newborn, fasting blood glucose, body mass index (BMI) and the presence or absence of chronic hypertension) to be entered in a logistic regression model. Discrimination and calibration measures were evaluated after an internal validation step using standard bootstrapping techniques. After the model was built, we enrolled another 200 women to externally validate the model. For the external validation study, 6 more hospitals provided patients.ResultsThe individual risk of recurrence of early-onset preeclampsia using our formula can be calculated as follows: P(recurrence) = 1/(1 + e−(linear predictor)), with linear predictor = 0.29–0.42 * fasting blood glucose (mmol/L) + 0.59 * hypertension (yes/no) – 0.01 * gestational age at the time of previous birth (days) – 0.41 * prior SGA (yes/no) + 0.01 * BMI (kg/m2).After internal validation, the area under the receiver operating characteristic (ROC) curve of the model was 0.65 (95% CI: 0.56–0.74) in the development sample, and was higher in the external validation sample (AUC = 0.76, 95% CI = 0.58–0.96), indicating that the model discriminates well between women who will develop a recurrence and those who will not. Using a predicted risk threshold of, for example, 4.6%, about one-fourth of the population would be regarded low-risk with a negative predictive value of 100%. Calibration was satisfactory in both samples.Conclusion
Our model is helpful in the identification of women at very low risk of recurrent early-onset preeclampsia, and may be used to stratify women into normal care and intensified care groups. At present, we are conducting the PreCare study, in which we assess the effects and costs of introducing our prediction model into routine clinical practice.
[Show abstract][Hide abstract] ABSTRACT: Women who suffered from pregnancy complications seem at higher risk for mental health problems. A common pregnancy complication is preeclampsia (PE) and the HELLP syndrome.Objectives
To review the literature and to investigate whether former PE/HELLP patients are more likely to have mental health problems or more severe mental health problems, as compared to women without a history of PE/HELLP, and to investigate whether PE/HELLP is an independent risk factor for developing mental health problems.Methods
We performed a systematic search on PubMed and PsycInfo in July 2011. Studies had to present original data, consider postpartum depression, anxiety, or posttraumatic stress as outcomes, include both women with a history of PE/HELLP syndrome and at least one comparison group of women who had not experienced PE/HELLP, present the results for each group separately, or present the results of a multivariate regression analysis in which the diagnosis of PE/HELLP was considered as a factor, or both. Information on study design, participants and outcomes of interest for the current review were extracted using a prespecified form. Furthermore, a short critical appraisal checklist was used in order to evaluate the appropriateness of the studies in light of our specific review questions. For the purpose of the second review question, confounder control and handling of intermediate variables were specifically considered important.ResultsThe search resulted in 227 articles, of which six were included. Four studies were historical cohort studies, two prospective.With respect to depression, the evidence is mixed. Out of the six studies addressing depression, all studies showed positive associations between PE/HELLP and the prevalence of depression or severity of depressive symptoms. However, the results of three of them were not statistically significant. The two studies addressing anxiety did not show a statistically significant association between PE and anxiety scores, although differences were in the expected direction (i.e. higher scores among women with PE). In the four studies addressing posttraumatic stress, associations were generally in the expected direction (i.e. higher prevalence and severity among women with PE/HELLP), but only a minority of them was statistically significant or partly significant. In most studies, confounder control was poor.Conclusion
Current evidence supporting a higher prevalence and an increased severity of mental health problems after PE/HELLP than after an uneventful pregnancy is inconclusive. Future studies should be prospective in design and should control for more possible confounders.
[Show abstract][Hide abstract] ABSTRACT: To develop a model to identify women at very low risk of recurrent early-onset preeclampsia.
We enrolled 407 women who had experienced early-onset preeclampsia in their first pregnancy, resulting in a delivery before 34 weeks' gestation. Preeclampsia was defined as hypertension (systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg) after 20 weeks' gestation with de novo proteinuria (≥300 mg urinary protein excretion/day). Based on the previous published evidence and expert opinion, 5 predictors (gestational age at previous birth, prior small-for-gestational-age newborn, fasting blood glucose, body mass index, and hypertension) were entered in a logistic regression model. Discrimination and calibration were evaluated after adjusting for overfitting by bootstrapping techniques.
Early-onset disease recurred in 28 (6.9%) of 407 women. The area under the receiver operating characteristic (ROC) curve of the model was 0.65 (95% CI: 0.56-0.74). Calibration was good, indicated by a nonsignificant Hosmer-Lemeshow test (P = .11). Using a predicted absolute risk threshold of, for example, 4.6% (ie, women identified with an estimated risk either above or below 4.6%), the sensitivity was 100%, with a specificity of 26%. In such a strategy, no women who developed preeclampsia were missed, while 98 of the 407 women would be regarded as low risk of recurrent early-onset preeclampsia, not necessarily requiring intensified antenatal care.
Our model may be helpful in the identification of women at very low risk of recurrent early-onset preeclampsia. Before widespread application, our model should be validated in other populations.
[Show abstract][Hide abstract] ABSTRACT: Preeclampsia and HELLP syndrome may have serious consequences for both mother and fetus. Women who have suffered from preeclampsia or the HELLP syndrome, have an increased risk of developing preeclampsia in a subsequent pregnancy. However, most women will develop no or only minor complications. In this study, we intend to determine cost-effectiveness of recurrence risk guided care versus care as usual in pregnant women with a history of early-onset preeclampsia.
We developed a prediction model to estimate the individual risk of recurrence of early-onset preeclampsia and the HELLP syndrome. In a before-after study, pregnant women with preeclampsia or HELLP syndrome in their previous pregnancy receiving care as usual (before introduction of the prediction model) will be compared with women receiving recurrence risk guided care (after introduction of the prediction model). Eligible and pregnant women will be recruited at six university hospitals and seven large non-university tertiary referral hospitals in the Netherlands. The primary outcome measure is the recurrence of early-onset preeclampsia or HELLP syndrome in women allocated to the regular monitoring group. For the economic evaluation, a modelling approach will be used. Costs and effects of recurrence risk guided care with those of care as usual will be compared by means of a decision model. Two incremental cost-effectiveness ratios will be calculated: 1) cost per Quality Adjusted Life Year (mother unit of analysis) and 2) cost per live born child (child unit of analysis).
This is, to our knowledge, the first study that evaluates prospectively the efficacy of a multivariable prediction rule for recurrent hypertensive disease in pregnancy. Results of this study could either be integrated into the current guideline on Hypertensive Disorders in Pregnancy, or be used to develop a new guideline.