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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 348-358

The role of clinical and laboratory tests along with uterine artery Doppler indices in the prediction of pre-eclampsia and pregnancy outcome in Egypt


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Egypt
2 Department of Radiodiagnosis, South Egypt (Cancer Institute), Faculty of Medicine, Assiut University, Assiut, Egypt
3 Department of Radiology, Faculty of Medicine, South Valley University Qena, Egypt

Date of Submission06-Mar-2020
Date of Decision30-Jun-2020
Date of Acceptance29-Jul-2020
Date of Web Publication30-Oct-2020

Correspondence Address:
Osama Abdelazem
Faculty of Medicine, Al-Azhar University, Assiut, 11651
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_48_20

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  Abstract 


Background and aim As the ideal test to predict pregnancy-induced hypertension and preeclampsia should be inexpensive, reproducible, easy to do early in pregnancy, and noninvasive and have high sensitivity, the aim of this study was to evaluate clinical parameters, laboratory tests, and uterine artery doppler indices in prediction of preeclampsia and pregnancy outcome.
Patients and methods This study was carried out in the antenatal care clinic of Obstetrics and Gynecology Department of Al Azhar University Hospital. The study included 177 pregnant women booked for antenatal care before 18 weeks of gestation, who were considered to be at increased risk of developing preeclampsia.
Results Doppler flow velocimetry of the uterine artery at 18–20 and 22–24 weeks of gestation represents a useful predictive test in high-risk pregnancy and in predicting preeclampsia, when used as a single test. Microalbuminuria between 24 and 34 weeks of gestation, in the first morning urine specimen, is a good predictor for the subsequent development of preeclampsia.
Conclusion When three tests were combined to test their ability to predict preeclampsia, the best triple tests were microalbuminuria, uterine artery doppler flow velocimetry study at 24–26 weeks of gestation, and mean platelet volume, which gave the highest value when κ test of agreement was used.

Keywords: Doppler flow velocimetry, intrauterine growth retardation, preeclampsia, pregnancy, uterine artery


How to cite this article:
Sileem SA, El-Barody MM, Okasha A, Abdelazem O. The role of clinical and laboratory tests along with uterine artery Doppler indices in the prediction of pre-eclampsia and pregnancy outcome in Egypt. Al-Azhar Assiut Med J 2020;18:348-58

How to cite this URL:
Sileem SA, El-Barody MM, Okasha A, Abdelazem O. The role of clinical and laboratory tests along with uterine artery Doppler indices in the prediction of pre-eclampsia and pregnancy outcome in Egypt. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Dec 4];18:348-58. Available from: http://www.azmj.eg.net/text.asp?2020/18/3/348/299570




  Introduction Top


Preeclampsia is defined as a new onset of hypertension (>140/90 mmHg) appearing after 20 weeks of gestation and accompanied by proteinuria (>0.3 g/24 h) [1]. It is the leading cause of maternal mortality, intrauterine growth retardation (IUGR), and fetal prematurity, affecting 5%–10% of pregnancies worldwide. Various risk factors have been implicated including general factors such as primigravidity, young maternal age, maternal age more than 35 years, low‑socioeconomic class, family history, multiple pregnancy, obesity, chronic hypertension, renal disease, thrombophilia, gestational diabetes, and connective tissue diseases.

The pathophysiology of preeclampsia is related to incomplete trophoblastic invasion of the myometrium, leading to limited remodeling of spiral arteries during the first and early second trimester. This defective trophoblastic invasion causes placental insufficiency and damage, leading to systemic inflammatory response, which in turn leads to vascular endothelial dysfunction and damage. This manifests clinically as hypertension, proteinuria, and other systemic responses. It is known that the impaired placental perfusion caused by vascular abnormalities precedes clinical manifestations of preeclampsia [2].

Measurement in early pregnancy of a variety of biological, biochemical, and biophysical markers implicated in the pathophysiology of preeclampsia has been proposed to predict its development. Investigators have attempted to identify early markers of faulty placentation, reduced placental perfusions, endothelial cell activation and dysfunction, and activation of coagulation. Attempts thus far have resulted in strategies with poor sensitivity and with poor positive predictive value for preeclampsia [3].

Currently, there are no screening tests for preeclampsia that are reliable, valid, and economical. Thrombocytopenia and platelet dysfunction are the integral feature of preeclampsia. Increased destruction causes platelet volume to increase, because of relatively younger and therefore larger platelets [4].

Hasslacher et al. [5] found high platelet volume to be a marker of impending preeclampsia. The passage from normal to pathological albuminuria is unlikely to occur abruptly. Persistent heavy proteinuria is almost always preceded by a variable period of intermittent and higher proteinuria, and this is likely to be preceded by an even longer period of slowly increasing microalbuminuria [6].

Preeclampsia, fetal growth retardation, or both are often associated with defective trophoblastic invasion. Indirect evidence of the depth of invasion is determined by Doppler ultrasound examination of the uterine circulation; for this reason, the use of the Doppler waveforms as a screening test for disorders associated with poor placental perfusions has been evaluated by several investigators [7].


  Patients and methods Top


This study was carried out in the antenatal care clinic of Obstetrics and Gynecology Department of Al Azhar University Hospital, with the aim to evaluate clinical parameters, laboratory tests, and uterine artery Doppler indices in the prediction of preeclampsia and pregnancy outcome. The study protocol was approved by the ethics committee of Faculty of Medicine, Al Azhar University Council.

Patients

The study included 177 pregnant women booked for antenatal care before 18 weeks of gestation, who were considered to be at increased risk of developing preeclampsia. The study included primigravidas, multigravidas with multiple pregnancy, previous poor pregnancy outcome, past history or family history of preeclampsia, previous small for gestational age (SGA), age more than 35 years, age less than 17 years, obese women, chronic hypertension, and diabetes mellitus.

All cases were recruited in a full antenatal program, including the following:
  1. History and examinations:
    1. History: personal, present, past, family, menstrual, and obstetric history.
    2. General examination:


Body built, weight, height, BMI, and gait.

BMI:

It was calculated from the following equation:

BMI=body weight in kg/(height in m2).

Vital signs: blood pressure–pulse–temperature–respiratory rate.

The mean arterial blood pressure (MAP):

The mid trimester MAP was calculated by the following equation:

MAP=diastolic blood pressure+1/3 (systolic blood pressure-diastolic blood pressure).

MAP of more than or equal to 90.5 mmHg was chosen as determined by the receiver operator characteristic curve (ROC) as a predictive of preeclampsia.

Roll over test: this test was performed between 28 and 32 weeks of pregnancy with the woman lying on her left side until the diastolic blood pressure, measured in the uppermost right arm is stable. The woman is then turned on her back, and the diastolic blood pressure is again recorded. A rise in diastolic blood pressure of greater than or equal to 20 mmHg defines a positive test result.
  1. Chest and heart examination.
  2. Obstetric examination.
    1. Laboratory investigations:
      1. Routine laboratory investigation.
      2. Predictive laboratory tests for preeclampsia:
        1. Mean platelet volume:
          1. It is the mean cell volume of platelets. It is measured in femtoliters.
          2. fl=10ˉ15l.
          3. MPV data are generated‚ at no extra cost‚ as part of the full blood count profile.
          4. MPV was available for analysis at 28 weeks of gestation.
          5. MPV of more than or equal to 10.1 fl was chosen as determined by the ROC as a predictive of preeclampsia.
        2. Microalbuminuria:
          1. Microalbuminuria is defined as excretion of albumin between 20 and 200 μg/l of urine.
          2. Micral test strips were used to determine whether the urine samples were positive or negative for microalbuminuria.
        3. Ultrasonographic and Doppler studies:


Ultrasonographic examinations were performed using a model Toshiba SSA 270A (Japan) mounted with 3.75 MHz curvilinear transducer and vaginal probe 7.5 MHz: routine ultrasound examination and Doppler examination.

Doppler examination

Pulsed wave Doppler equipment was used to obtain the arterial velocity waveform of uterine arteries.

Timing of doppler examination

Doppler study of the uterine artery was performed at 18–22 weeks of pregnancy. If waveforms are deemed to be abnormal, it is repeated at 24–26 weeks of pregnancy.

Follow-up for all cases was done till delivery for the assessment of the following:
  1. The maternal general condition.
  2. Detection of pregnancy complication:
    1. Occurrence of preeclampsia.
    2. Abruption placenta.
    3. Intrauterine growth restriction.
    4. Intrauterine fetal death.
  3. Fetal growth and well-being.
  4. Mode of delivery.
  5. Neonatal outcome:
    1. Gestational age at delivery.
    2. Birth weight.
    3. Apgar score at 1 and 5 min.
    4. The need for admission to the neonatal intensive care unit.


Statistical analysis

Data were coded and entered to Statistical Package for the Social Sciences version 8. ROC curve was used to choose the cutoff value of the BMI, the mean arterial pressure, and the mean platelet volume.

The data were analyzed by using the following:
  1. Student t-test for comparison between two sample means:
    1. If the P value less than 0.05 was considered statistically significant.
    2. P value less than 0.01 was considered statistically highly significant.
    3. P value more than 0.05 was considered statistically nonsignificant.
  2. The validity of screening tests including the sensitivity, specificity positive predictive value, negative predictive value, and accuracy.
  3. The κ test of agreement.



  Results Top


The current was performed at Hospital of Al-Azhar Assiut University. It was conducted in a period between May 2018 and May 2019. The study enrolled 177 high-risk pregnant women attending the antenatal clinic before 18 weeks of gestation. Of those women, seven were lost during the follow-up and were excluded from data analysis. Finally, 170 women were enrolled for analysis.

Frequency of pre-eclampsia in this study

Of the enrolled women, 20 (12%) pregnant women developed preeclampsia during follow-up (preeclampsia group), whereas 150 (88%) pregnant women remained normotensive (control group) ([Figure 1] and [Figure 2]).
Figure 1 Frequency of preeclampsia in the current study. Of the enrolled women, 20 (12%) pregnant women developed preeclampsia during follow-up (preeclampsia group), whereas 150 (88%) pregnant women remained normotensive (control group).

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Figure 2 Doppler ultrasound of pregnant women. A pregnant woman aged 17 years old Prim gravid LMP gestational age: 23 weeks+5 days, US gestational age: 20 weeks, First trimester uterine Doppler findings (Al,2) PI: RT: 3.15, LT:3.50, with bilateral diastolic notch (arrow), Second trimester uterine Doppler findings (B 1,2) PI: RT:2.08, LT•.1.87, umbilical artery doppler (C) with no diastolic flow. She developed preeclampsia, at 23 weeks gestation. LMP, last menstrual period; US, ultrasound.

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Baseline clinical data of the studied women

[Table 1] shows that there is a significant difference between the preeclampsia group and the control group regarding parity (1.70±0.94 vs 1.80±0.98; P=0.03). There was no significant difference between both groups regarding the age, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and BMI.
Table 1 Baseline clinical data of the studied women

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The pregnancy outcome of the two studied groups

It was noticed that frequency of IUGR, preterm labor, delivery by cesarean section, low Apgar score at 5 min, low birth weight, and neonatal death was significantly higher among preeclampsia group ([Table 2]).
Table 2 The pregnancy outcome of the two studied groups

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Diagnostic performance of BMI for the prediction of poor outcome

It was noticed that BMI at a cutoff point of greater than or equal to 30.5 kg/m22 is statistically significant for the prediction of preeclampsia and shows no significance for the prediction of IUGR, preterm labor, delivery by cesarean section, low Apgar score at 5 min, the need for admission to neonatal ICU, or neonatal death ([Table 3]).
Table 3 Accuracy of body mass index for the prediction of poor outcome

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Diagnostic performance of the roll-over test for prediction of the poor outcome

This table shows that the roll-over test is not significant as a predictor of preeclampsia, IUGR, preterm labor, delivery by cesarean section, low Apgar score at 5 min, the need for admission to neonatal ICU. and neonatal death ([Table 4]).
Table 4 Accuracy of roll over test for the prediction of poor outcome

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Diagnostic performance of Doppler velocity wave for prediction of poor outcomes at 18–22 weeks of gestation

It was noticed that abnormal Doppler velocity waveform of the uterine artery at 18–22 weeks of gestation is highly significant in the prediction of preeclampsia and IUGR, but it was significant for prediction of preterm labor and the need for neonatal ICU admission. It was insignificant in the prediction of cesarean section delivery, low Apgar score at 5 min, and neonatal deaths ([Table 5]).
Table 5 Performance (Dop1) for prediction of poor outcome at 18–22 weeks’ gestation

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Diagnostic performance of Doppler velocity wave for prediction poor outcomes at 24–26 weeks of gestation

This table shows that abnormal Doppler velocity waveform of the uterine artery at 24–26 weeks of gestation is highly significant in the prediction of preeclampsia, IUGR, preterm labor, low Apgar score at 5 min, and the need for admission to neonatal ICU, and it was significant in the prediction of neonatal death ([Table 6]).
Table 6 Performance (Dop1) for prediction of poor outcome at 24–26 weeks’ gestation

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Abnormal uterine artery Doppler velocity wave form at 24–26 weeks of gestation as a predictor of cesarean section delivery is not significant.

Combined MAP with different variables for the prediction of preeclampsia

This table shows that MAP when combined with microalbuminuria is highly significant for the prediction of preeclampsia, whereas combining it with roll over test (ROT) or abnormal uterine artery Doppler velocity waveform at 24–26 weeks of gestation gives significant results, and insignificant results are obtained when combined with the BMI or the mean platelet volume ([Table 7]).
Table 7 MAP with different variables for the prediction of preeclampsia

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Combined BMI with different variables in prediction of preeclampsia

This table shows that combining BMI with microalbuminuria or abnormal uterine artery Doppler flow velocity waveform at 24–26 weeks of gestation is highly significant for predicting preeclampsia, whereas it is significant when combined with the roll-over test or the mean platelet volume ([Table 8]).
Table 8 BMI with different variables in prediction of preeclampsia

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Combined ROT with different variables for prediction of preeclampsia

This table shows that combined ROT with microalbuminuria or abnormal uterine artery Doppler flow velocity waveform at 24–26 weeks of gestation is highly significant in predicting preeclampsia, whereas it is insignificant when combined with the mean platelet volume ([Table 9]).
Table 9 ROT with different variables for prediction of preeclampsia

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Combined microalbuminuria with MPV, microalbuminuria with Doppler, and MPV with Doppler for prediction of preeclampsia

This table shows that combined microalbuminuria with MPV or with the abnormal uterine artery Doppler flow velocity waveform at 24–26 weeks of gestation is highly significant for the prediction of preeclampsia. Combined mean platelet volume with the abnormal uterine artery Doppler flow velocity waveform at 24–26 weeks of gestation is highly significant for the prediction preeclampsia ([Table 10]).
Table 10 Combined microalbuminuria with MPV, microalbuminuria with Doppler, and MPV with Doppler for prediction of preeclampsia

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The efficacy of triple tests for predicting preeclampsia

Combined abnormal uterine artery Doppler flow velocity waveform at 24–26 weeks of gestation with microalbuminuria and BMI is highly significant in predicting preeclampsia. Combined abnormal uterine artery Doppler flow velocity waveform at 24–26 weeks of gestation with microalbuminuria and MPV is highly significant in predicting preeclampsia ([Table 11]).
Table 11 Efficacy of triple tests for predicting preeclampsia

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Combined abnormal uterine artery Doppler flow velocity waveform at 24–26 weeks of gestation with ROT and MAP is highly significant in predicting preeclampsia. From this comparison, when three tests were combined to test their ability to predict preeclampsia, although the sensitivity decreased, the positive predictive value increased to 100%, and the best triple was combined abnormal uterine artery Doppler flow velocity waveform at 24–26 weeks of gestation with microalbuminuria and MPV, which gave the highest value when κ test of agreement was used ([Table 11]).


  Discussion Top


In our study, regarding the relation of the BMI and preeclampsia, we found that of the 170 cases that completed this study, 24 cases showed a BMI greater than or equal to 30.5 kg/m2 (14.1%), comprising 6 cases that developed preeclampsia (25%) and 18 cases that remained normotensive throughout pregnancy (75%). Of the 146 cases that had BMI less than 30.5 kg/m2, 13 cases subsequently developed preeclampsia (8.9%) and 133 cases remained normotensive (91.1%). This gave the test a sensitivity of 32.04%, specificity of 89.1%, positive predictive value of 22.1%, and a negative predictive value of 92.2%, which was statistically significant for predicting preeclampsia.

In agreement with our result, Sibai et al. [8] revealed that BMI greater than or equal to 35 kg/m2 vs less than 19.8 kg/m2 was statistically significant for predicting preeclampsia, and also, Suzuki et al. [9] concluded that in singleton pregnancies, the incidence of maternal preeclampsia in the high-BMI group was significantly higher than that in the normal-BMI group. The relative risk by high BMI was 8.5 (95% confidence interval: 5.6–12.0). However, in twin pregnancies, no significant differences were observed in these values.

To reveal the role of roll-over test in predicting preeclampsia, of the 170 cases entered in our study, 46 cases showed a positive roll-over test, comprising six cases that developed preeclampsia (13.1%) and 40 cases that remained normotensive throughout pregnancy (86.9%). Of the 124 women who showed negative roll over test result, 13 cases subsequently developed preeclampsia (10.5%) and 111 cases remained normotensive (89.5%). This gave the test a sensitivity of 33.12%, specificity of 74.44%, positive predictive value of 13.33%, and a negative predictive value of 90.13%, which was statistically nonsignificant in predicting preeclampsia.

Various factors may explain the marked disparity in results of a relatively simple test as the roll-over test. Although all investigators define an increase in diastolic blood pressure of 20 mmHg as a positive test result, there was considerable variation among investigators in the method of the test and the measurement of blood pressure (using Korotkoff phase 4, phase 5, or Doppler-shift signals). In addition, there were usual inconsistencies in the definition of preeclampsia. Moreover, most authors, with only a few exceptions, failed to identify the arm used to record blood pressure. This is of great importance, as turning the patient from the left side on to her back with blood pressure recorded from the right (superior) arm will result in a predictable increase in diastolic pressure of ∼10–12 mmHg because of the increase in hydrostatic pressure relative to the level of the heart [10],[11].

In the current study, the elevated MAP was used as a screening test for preeclampsia. Using the ROC curve, the threshold value of greater than or equal to 90.5 mmHg was chosen as a predictor for the development of preeclampsia. It had a sensitivity of 26.4%, specificity of 73% positive predictive value of 11%, and a negative predictive value of 90.1%, which was statistically nonsignificant in prediction of preeclampsia.

Conde-Augedelo et al. [12] studied the predictive performance of the MAP greater than or equal to 85 mm/Hg at 26 weeks of gestation, which gave a sensitivity of 74%, specificity of 72% positive predictive value of 32%, and negative predictive value of 95%. Moreover, Gant et al. [13] studied the predictive performance of the MAP greater than or equal to 87 mm/Hg at 26 weeks of gestation, which gave a sensitivity of 46%, specificity of 88% positive predictive value of 23%, and negative predictive value of 92%.

Of the 170 cases that completed this study, 28 cases showed microalbuminuria (16.5%), comprising 17 cases that developed preeclampsia (60.5%) and 11 cases that remained normotensive throughout pregnancy (39.5%). Of the 142 cases that had no microalbuminuria, 1 case subsequently developed preeclampsia (0.72%) and 141 cases remained normotensive (99.28%). This gave a sensitivity of 94%, specificity of 93%, a positive predictive value of 59.8%, and a negative predictive value of 98.8%, which was statistically highly significant in predicting preeclampsia.

Our result matches with Rodriguez et al. [14] who studied microalbuminuria using radio-immunoassay in first-morning urine sample of 88 normotensive pregnant women of mixed parity between 24 and 34 weeks of gestation. With the use of the ROC curve, a urine albumin concentration of greater than 11 μg/ml was chosen as a predictor for development of preeclampsia. This gave the test a sensitivity of 50%, specificity of 82%, a positive predictive value of 26%, and a negative predictive value of 93%. Moreover, Salako et al. [15] concluded that urinary microalbuminuria at booking as a predictor of preeclampsia is statistically significant, with a high sensitivity but a low positive predictive value. Their results had a sensitivity of 88.9%, specificity of 67.9%, positive predictive values of 22.2% and negative predictive value of 98.3%.

Lara Gonzalez et al. [16] studied 102 women who had risk factors for preeclampsia with a pregnancy between 16 and 18 weeks. An evaluation of microalbuminuria was done through a clean-catch dipstick of the first micturition of the day. It gave a sensitivity of 79%, specificity 63%, positive predictive value of 46%, and negative predictive value of 88%. They concluded that microalbuminuria in early stages of pregnancy could be a good predictor of preeclampsia. However, published results are controversial regarding the use of microalbuminuria as an early predictor of preeclampsia.

The results of this study showed that MPV was significantly higher in patients who later on developed preeclampsia than in those who remained normotensive throughout pregnancy (9.99±1.35 in preeclamptic group vs 8.33±0.94 in normal group). With the use of the ROC curve, a MPV of greater than or equal to 10.1 fl was chosen to predict the development of preeclampsia, which gave a sensitivity of 44.34%, specificity of 81.3%, a positive predictive value of 24.4%, and a negative predictive value of 92.1% which was significant for predicting preeclampsia, which was statistically significant.

In consistent with our study, Walker et al. [17] studied 300 normal primigravid pregnancies between 28 and 30 weeks of gestation, and it was felt that platelet volume may not be a useful screening test in a low-risk population. It was found that 8 of the 154 patients who had a mean platelet volume greater than 8.5 went on to develop severe preeclampsia, whereas only one of the 146 patients who had a mean platelet of less than 8.5 developed severe preeclampsia; although it was statistically significant, it is of little clinical significance, with a positive predictive value of only 5.19%.

Moreover, Giles [18] concluded that patients with preeclampsia and uncomplicated hypertension in late pregnancy tended to have lower platelet counts and larger platelets than controls.

A second study was carried out to investigate the serial changes in these parameters in patients at risk of progressive disease. The mean platelet volume increased significantly at least 1 week before the hypertension became clinically apparent. There was no change in platelet count at this time. It is concluded that increasing platelet size can predict which patients are likely to progress to severe disease before it becomes clinically obvious. They suggested that longitudinal determination of platelet volumes may be of use in identifying those women at risk of preeclampsia.

Bielecki et al. [19] concluded that mean platelet volume was significantly higher in patients with preeclampsia (9.5 vs 8.6 fl).

Of the 170 cases entered in our study, 16 cases showed persistent abnormal Doppler velocimetry of uterine arteries (9.4%); 13 of them developed preeclampsia (80.7%), and three cases remained normotensive throughout pregnancy (19.3%). Of the 154 women who had normal Doppler velocimetry of uterine arteries (90.6%), 6 cases subsequently developed preeclampsia (3.9%) and 148 cases remained normotensive (96.1%). This gave the test a sensitivity of 68.8%, specificity of 97.8%, positive predictive value of 78.6% and a negative predictive value of 96.3%, which was statistically highly significant for predicting preeclampsia.

The sensitivity, specificity, positive predictive value, and negative predictive value in predicting IUGR were 45.5, 93.5, 35.7, and 95.6%, respectively.

Caforio et al. [20] assessed the value of uterine artery Doppler velocimetry performed at 18–20 and 22–24 weeks of gestation in predicting preeclampsia and adverse pregnancy outcome in low- and high-risk women. At 18–20 weeks of gestation, the sensitivity for the prediction of preeclampsia was 100 and 94% in low- and high-risk groups, respectively. Negative predictive values toward birth weight less than 1750 g (97% in low-risk and 93% in high-risk groups) and delivery before 32 weeks of gestation (99% in low-risk and 95% in high-risk groups) were obtained. At 22–24 weeks of gestation, the sensitivity for the prediction of preeclampsia was 100 and 97% in low-risk and high-risk groups, respectively. Negative predictive values toward birth weight less than 1750 g were 97% in low-risk and 94% in high-risk groups, whereas toward delivery before 32 weeks of gestation were 98% in low-risk and 94% in high-risk groups.

Venkat-Raman et al. [21] assessed mid trimester uterine artery Doppler in the prediction of preeclampsia and SGA infants in women with the primary antiphospholipid syndrome. The diagnostic accuracy of the Doppler was limited to bilateral uterine artery notches at 22–24 weeks of gestation in the subgroup of women with positive lupus anticoagulant. In this subgroup, bilateral uterine artery notches at 22–24 weeks of gestation in predicting preeclampsia, generated a high probability for positive test of 12.8 (95% confidence interval: 2.2–75), with sensitivity of 75%, specificity of 94%, positive predictive value of 75%, and negative predictive value of 94%. In predicting SGA, the corresponding figures were 13.6 (95% confidence interval 1.9, 96), 80, 94, 80, and 94%. Uterine artery Doppler was of limited value in pregnancies associated with anticardiolipin antibodies in isolation.

Papageorghiou et al. [22] in a multicenter study studied the value of transvaginal color Doppler assessment of the uterine arteries at 23 weeks of gestation in predicting the subsequent development of preeclampsia and fetal growth restriction.

Phupong et al. [23] studied the efficacy of Doppler uterine artery in predicting the risk of preeclampsia and small-for-gestational-age infants in low-risk women. The sensitivity, specificity, positive predictive value, and negative predictive value for detecting preeclampsia were 36.8, 83.2, 12.1, and 95.5%, respectively, whereas detecting SGA infants were 67, 82.9, 6.9, and 99.2%, respectively.

In this study, the combination of abnormal uterine artery Doppler velocimetry at 24–26 weeks’ gestation with mean platelet volume greater than or equal to 10.1 fl gave a sensitivity of 18.2%, specificity of 97.1%, PPV of 33.3%, NPV of 93.8%, and accuracy of 91.3%. κ test of agreement gave a value of 0.194, which is statistically significant (P<0.05).

Missfelder-Lobos et al. [24] investigated whether, in women with the abnormal uterine artery Doppler, platelet volume and function will identify a subgroup of women at increased risk of preeclampsia and intrauterine growth restriction. Mean platelet volume was greater in those with abnormal Doppler who had intrauterine growth restriction or normal pregnancy outcome compared with normal Doppler (10.3 and 10.3 vs 9.4 fl, P=0.004 and 0.01, respectively). Women with an abnormal uterine artery Doppler at 23 weeks of gestation showed alterations in mean platelet volume and platelet function that related to the subsequent adverse outcome.


  Conclusion Top


This study concluded that Doppler flow velocimetry of the uterine artery at 18–20 and 22–24 weeks of gestation represents a useful predictive test in high-risk pregnancy and was better in predicting preeclampsia than IUGR. When used as a single test, microalbuminuria between 24 and 34 weeks of gestation, in the first morning urine specimen, is a good predictor for the subsequent development of preeclampsia (easy to perform, readily interpretable, and noninvasive, with good sensitivity and positive predictive values). When the three tests were combined to test their ability to predict preeclampsia, the best triple was microalbuminuria, uterine artery Doppler flow velocimetry study at 24–26 weeks of gestation, and MPV, which gave the highest value when κ test of agreement was used.

Recommendation

Based on the results, we recommend the following:
  1. The screening tests for the prediction of preeclampsia must be added to the schedule of the routine antenatal care, especially for the high-risk women.
  2. Adding of the uterine artery Doppler flow velocimetry at 24–26 weeks of gestation, microalbuminuria at 24–34 weeks of gestation, and mean platelet volume at 28 weeks of gestation to the program of antenatal care for prediction of preeclampsia, especially for the high-risk group.
  3. To obtain a universally acceptable and reliable screening test for the prediction of preeclampsia, further prospective studies are required.


Financial support and sponsorship

Nil.

AssiutConflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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