The established method of the assessment of the risk for development of preeclampsia
is to identify risk factors from maternal demographic characteristics and medical
history; in the presence of such factors, the patient is classified as high risk and
in their absence as low risk. Although this approach is simple to perform, it has
poor performance of the prediction of preeclampsia and does not provide patient-specific
risks. This review describes a new approach that allows the estimation of patient-specific
risks of delivery with preeclampsia before any specified gestational age by maternal
demographic characteristics and medical history with biomarkers obtained either individually
or in combination at any stage in pregnancy. In the competing risks approach, every
woman has a personalized distribution of gestational age at delivery with preeclampsia;
whether she experiences preeclampsia or not before a specified gestational age depends
on competition between delivery before or after the development of preeclampsia. The
personalized distribution comes from the application of Bayes theorem to combine a
previous distribution, which is determined from maternal factors, with likelihoods
from biomarkers. As new data become available, what were posterior probabilities take
the role as the previous probability, and data collected at different stages are combined
by repeating the application of Bayes theorem to form a new posterior at each stage,
which allows for dynamic prediction of preeclampsia. The competing risk model can
be used for precision medicine and risk stratification at different stages of pregnancy.
In the first trimester, the model has been applied to identify a high-risk group that
would benefit from preventative therapeutic interventions. In the second trimester,
the model has been used to stratify the population into high-, intermediate-, and
low-risk groups in need of different intensities of subsequent monitoring, thereby
minimizing unexpected adverse perinatal events. The competing risks model can also
be used in surveillance of women presenting to specialist clinics with signs or symptoms
of hypertensive disorders; combination of maternal factors and biomarkers provide
patient-specific risks for preeclampsia that lead to personalized stratification of
the intensity of monitoring, with risks updated on each visit on the basis of biomarker
measurements.
Key words
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Article info
Publication history
Published online: November 13, 2019
Accepted:
November 4,
2019
Received in revised form:
November 1,
2019
Received:
September 4,
2019
Footnotes
This work was supported by grants from the Fetal Medicine Foundation (Charity No: 1037116).
The Fetal Medicine Foundation had no involvement in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
The authors report no conflict of interest.
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© 2019 Elsevier Inc. All rights reserved.
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- How to calculate the risk of preeclampsia in women with a history of positive screeningAmerican Journal of Obstetrics & GynecologyVol. 223Issue 2
- PreviewWith the current demonstration of the benefits of aspirin initiated in early pregnancy to prevent the most severe and preterm forms of preeclampsia, there is a growing interest for the prediction of preterm preeclampsia in the first trimester of pregnancy.1 In the review by Wright et al,2 the authors reported that approximately 90% of women who will develop early preeclampsia could be identified using a competing risks approach in the first trimester of pregnancy, with a false-positive rate of 10%.
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