Diagnosis of Preterm Labor Advances in the Diagnosis of Preterm Labor PGN-EN-2015-09-B

Scope of the Problem Drawbacks of Current Methods

Preterm Labor (PTL) is a Major Diagnostic Challenge Up to 30% of patients presenting with signs of PTL are admitted 1,2 Only 5-10% of these patients go on to deliver within 7 days 3,4 This results in up to 85% of patients admitted unnecessarily 5 A more accurate assessment of patients with signs and symptoms of preterm labor is urgently needed to identify those truly at risk 1. Sanchez-Ramos L et al. ObstetGynecol 2009;114: 631-40. 2. Schaaf JM et al. BJOG 2011;118:1196-204. 3. McPheeters ML et al. Am J Obstet Gynecol 2005;192:1325-9. 4. Ness A et al. Am J Obstet Gynecol 2007;197:426.e1–426.e7 5. Alfirevic Z et al. Ultrasound Obstet Gynecol 2007; 29: 47–50

Scope of the Problem Drawbacks of Current Methods

PTL Symptoms Alone are Insufficient for Diagnosis Clinical symptoms traditionally utilized for the assessment of threatened preterm labor alone have proven insufficient for the prediction of imminent spontaneous preterm birth Test1 Sensitivity (%) Specificity (%) PPV (%) NPV (%) Contractions ≥ 4/hr 58 45 7 94 ≥ 6/hr 55 9 95 ≥ 8/hr 42 67 Iams J et al. Am J Obstet Gynecol. 1995 Jul;173(1):141-5.

Clinical Utility of Cervical Length is Limited Cervical Length measurement by transvaginal ultrasound (CL) is the most useful biophysical marker for predicting spontaneous preterm delivery CL has its highest NPV in long cervical lengths But, its PPV is very low in short cervical lengths Approximately 55% of patients fall inside the non-obvious cervical length range (15-30mm)2 1. Boots et al. Am J Obstet Gynecol. 2014 Jan;210(1):54.e1-54.e10. 2. Tsoi E et al. Ultrasound Obstet Gynecol 2005; 25: 353–356.

Traditional Biomarker Tests Have Same Limitations Traditional biomarker tests (i.e. based on fFN and phIGFBP-1) offer little to no performance advantages over CL with a cutoff of 25 mm Test Sensitivity (%) Specificity (%) PPV (%) ≤ 7 days NPV (%) Cervical Length (<25)1 57% 73% 30% 89% Fetal Fibronectin2-7 68% 85% 32% 92% phIGFBP-12-7 58% 82% 24% Low positive predictive value of traditional biomarker tests relegate them as “rule-out” tests only 1. Nikolova T etal. J Perinat Med. 2015 Jan 6. [Epub ahead of print] 2. Turnell R et al. Journal of Obstetrics and Gynaecology Canada 2005;27 (5 Suppl):S17. 3. Ting HS et al. Annals Academy of Medicine Singapore 2007;36(6):399-402. 4. Eroglu D et al. Gynecologic and Obstetric Investigation 2007;64(2):109-16. 5. Audibert F et al. Journal of Obstetrics & Gynaecology Canada, 32(4):307-12, 2010 Apr. 6. Cooper S et al. Journal of Perinatology, 32(6):460-5, 2012 Jun. 7. Crofts J. The limitations of the predictive tests currently available to assess threatened preterm labour. 2014: V16 N4: 30-31

Scope of the Problem Drawbacks of Current Methods

PAMG-1: A Biomarker with Enhanced Clinical Utility Placental alpha- microglobulin-1 (PAMG-1) The PartoSure Test detects PAMG-1, a protein found in very high concentrations in amniotic fluid and in very low concentrations in normal vaginal discharge Recent clinical studies have demonstrated a strong correlation between a positive PAMG-1 test and imminent delivery in patients presenting with threatened preterm labor and intact membranes Lee, Romero et al. postulated two possible explanations for the presence of PAMG-1 in cases of threatened preterm labor: Transudation of PAMG-1 through chorioamniotic pores in fetal membranes during uterine contractions Degradation of extracellular matrix of fetal membranes due to inflammatory process of labor and/or infection 1. Lee MS et al. J Matern Fetal Neonatal Med. 2012 Sep;25(9):1690-8. 2. Kobayashi K et al. J Physiol 588.24. 2010:4859-4869.

PartoSure: A Novel PAMG-1 Test for Assessing PTB The PartoSure test is an aid to rapidly assess the risk of preterm delivery within ≤7 or ≤14 days from the time of cervicovaginal sample collection in pregnant women with: Signs and symptoms of early preterm labor Intact amniotic membranes Between 20 weeks, 0 days and 36 weeks, 6 days gestation Specifically, the PartoSure test: Can be used with or without a speculum examination Can be used in the presence of vaginal infections, urine, semen, and blood (50% admixture)

PartoSure is a Rapid, Qualitative, Easy-to-Use Test Collect sample of vaginal discharge with sterile collection swab (speculum examination optional) Rinse specimen swab in solvent vial. Discard swab Insert test strip into vial and remove if 2 lines are visible, or at 5 minutes sharp Test strip is extracted from vial and results observed and recorded

PartoSure is Highly Predictive of Imminent Birth PartoSure has consistently demonstrated a high negative predictive value (NPV) and a superior positive predictive value (PPV) in peer-reviewed publications Explanation for statement, “PartoSure may reduce unnecessary admissions by up to 80%” -Assumption 1: Patient is admitted when a biomarker test alone is positive. -Assumption 2: fFN is positive X% of the time. When fFN is positive, it is incorrect Y% of the time. So, the chance of getting an unnecessary admission when relying on fFN alone is Z% (or, X% x Z%). -Assumption 3: PartoSure is positive A% of the time. When PartoSure is positive, it is incorrect B% of the time. So, the chance of getting an unnecessary admission when relying on PartoSure alone is C% (or, A% x B%). -Calculation: [1-(C/Z))=R% -Conclusion: PartoSure may reduce unnecessary admissions by up to R%. Values (from Di Renzo et al. 2015): X= .32 Y= .71 Z= (.32 x .71) = .2272 A= .18 B= .24 C= (.18 x .24) = .0432 R= .8098 Study N Sensitivity (%) Specificity (%) PPV (%) NPV (%) Di Renzo et al. 20151 203 80 95 76 96 Bolotskih et al. 20152 49 100 98 75 Nikolova et al. 20143 101 90 94 78 97 Di Renzo GC et al. J Perinat Med. 2015 Jan 6. [Epub ahead of print] Bolotskikh VM. Scientific and Practical Journal of Obstretrics and Gynecology Russian Federation. 2015 N2: 94-98 Nikolova T et al. J Perinat Med. 2014 Jul;42(4):473-7.

PartoSure is More Accurate than Traditional Tests Head-to-Head Study “ PartoSure is the single most accurate test when compared to fFN and CL for prediction of imminent spontaneous delivery in patients presenting with signs, symptoms, or complaints suggestive of PTL. ” Nikolova T et al. J Perinat Med. 2015 Jan 6. [Epub ahead of print]

PartoSure May Improve Accuracy in Equivocal CLs Cervical length measurement (CL) is least accurate as a predictor of imminent spontaneous delivery when it is between 15 & 30 mm If CL is used as an initial screen, PartoSure can be used to improve diagnostic value of CL when it falls in the ‘non-obvious’ range of 15 & 30 mm +12% CL between 15 & 30 mm +44% Di Renzo GC et al. J Perinat Med. 2015 Jan 6. [Epub ahead of print] Bolotskikh VM. Scientific and Practical Journal of Obstretrics and Gynecology Russian Federation. 2015 N2: 94-98

PartoSure May Improve Accuracy in Equivocal CLs Z.O.L. Hospital, Belgium – Ongoing Clinical Study 12th World Congress of Perinatal Medicine in Madrid, Spain +46% +33% N=35 N=19 “ The PAMG-1 test is more accurate than the fFN test at predicting imminent spontaneous delivery in symptomatic patients. Our data suggests that use of the PAMG-1 test may reduce unnecessary admissions and drug administration by up to 72%. ” Van Holsbeke et al. WCPM 2015 (submitted abstract)

Table 2. Predictive Biochemical Markers of Preterm Labor PartoSure Has Been Recognized in Guidelines In May 2014, SEGO (Spanish OBGYN Society) published PTL diagnosis guidelines identifying PAMG-1 as the marker with the highest sensitivity and PPV Table 2. Predictive Biochemical Markers of Preterm Labor   PPV NPV Sensitivity Specificity 7 days 14 days fFN 32% 39% 89% 56% 61% 76% 78% phIGFBP-1 46% 92% 69% 72% 80% PAMG-1 87% 97% 93% 90% 96% “Although the PPV and the sensitivity of PAMG-1 are the highest, the main utility of this test, is its high negative predictive value; its prognostic capacity increases in populations with high prevalence of prematurity.” Amenaza de parto pretérmino. Protocolos Asistenciales en Obstetricia. SEGO May 2014

Superior Diagnosis Reduces Unnecessary Treatment When a presumed diagnosis of preterm labor has been made, tocolysis is commenced to delay labor thus allowing time for the administration of a full course of corticosteroids1 Multiple courses of antenatal corticosteroids, given every 14 days, are associated with decreased growth in utero and no neonatal benefits compared with one course1 Current benefit and risk data are insufficient to support routine use of repeat or rescue courses of antenatal corticosteroids in clinical practice2 In women who remain at increased risk of preterm birth after receiving an initial course of antenatal corticosteroids, multiple courses are not recommended3 Avoiding unnecessary treatments reduces maternal & neonatal side effects3,4,5 Alfirevic Z et al. Ultrasound Obstet Gynecol 2007; 29: 47–50. Antenatal corticosteroids revisited: repeat courses. NIH Consensus Statement 2000;17(2): 1-18. Murphy KE et al. Lancet. 2008 Dec 20;372(9656):2143-51. 4. Guinn DA et al. JAMA 2001; 286: 1581–1587. 5. Gyetvai K et al. Obstet Gynecol 1999; 94:869–877.

Avoiding Unnecessary Treatment Benefits Patients Maternal Side Effects of Tocolytics1 Neonatal Side Effects of Multiple Rounds Corticosteroids2,3 Increased risk of maternal palpitations Lower birth weight Nausea Smaller head circumference Tremor Shorter height Chorioamnionitis Hyperglycemia Hypokalemia As treatment leads to substantial costs and discomfort for the mother, appropriate identification of women at low risk of immediate preterm delivery could reduce unnecessary treatment in these women, resulting in cost savings 4-6 Gyetvai K et al. Obstet Gynecol 1999; 94:869–877. Guinn DA et al. JAMA 2001; 286: 1581–1587. Murphy KE et al. Lancet. 2008 Dec 20;372(9656):2143-51. 4. French NP et al. Am J Obstet Gynecol 2004;190: 588-95. 5. Oei SG et al. N Engl J Med 1999;340:154. 6. van Veen AJ et al. BJOG2005;112: 509-10.

“ ” Superior Diagnosis Reduces Unnecessary Admissions fFN1 32% 29% 71% “Admit” fFN1 32% 29% 71% 68% 87% 13% Necessary + Fetal Fibronectin (fFN) Unnecessary Key Points - Average cost of an unnecessary admission estimated at 1,907€1 PartoSure may reduce unnecessary admissions by up to 80%2 “Discharge” “Admit” PAMG-11 18% 76% 24% 82% 96% 4% Necessary + Unnecessary Explanation for statement, “PartoSure may reduce unnecessary admissions by up to 80%” -Assumption 1: Patient is admitted when a biomarker test alone is positive. -Assumption 2: fFN is positive X% of the time. When fFN is positive, it is incorrect Y% of the time. So, the chance of getting an unnecessary admission when relying on fFN alone is Z% (or, X% x Z%). -Assumption 3: PartoSure is positive A% of the time. When PartoSure is positive, it is incorrect B% of the time. So, the chance of getting an unnecessary admission when relying on PartoSure alone is C% (or, A% x B%). -Calculation: [1-(C/Z))=R% -Conclusion: PartoSure may reduce unnecessary admissions by up to R%. Values (from Di Renzo et al. 2015): X= .32 Y= .71 Z= (.32 x .71) = .2272 A= .18 B= .24 C= (.18 x .24) = .0432 R= .8098 - “Discharge” That the PartoSure test was found to be statistically superior to fFN and CL with respect to SP and PPV (P < 0.01) provides evidence toward being able to significantly enhance current practice to ultimately reduce the unnecessary administration of potentially harmful therapeutics to patients, as well as reduce the economic burden associated with unnecessary hospital admissions. “ ” 1. O’Sullivan et al. JOGS 2014 (abstract) 2. Nikolova T et al. J Perinat Med. 2015 Jan 6. [Epub ahead of print]

“ ” Superior Diagnosis Reduces Unnecessary Admissions – 4,000 Births “Admit” 400 128 37 91 68% 87% 13% Necessary + Fetal Fibronectin (fFN) Unnecessary Key Points - Average cost of an unnecessary admission estimated at 1,907€ - £1,4501 PartoSure could produce 74 less unnecessary admissions per annum compared with fFN. PartoSure may reduce unnecessary admissions by up to 80%2- Reduction in transfers “Discharge” “Admit” 400 72 55 17 82% 96% 4% Necessary + Unnecessary Explanation for statement, “PartoSure may reduce unnecessary admissions by up to 80%” -Assumption 1: Patient is admitted when a biomarker test alone is positive. -Assumption 2: fFN is positive X% of the time. When fFN is positive, it is incorrect Y% of the time. So, the chance of getting an unnecessary admission when relying on fFN alone is Z% (or, X% x Z%). -Assumption 3: PartoSure is positive A% of the time. When PartoSure is positive, it is incorrect B% of the time. So, the chance of getting an unnecessary admission when relying on PartoSure alone is C% (or, A% x B%). -Calculation: [1-(C/Z))=R% -Conclusion: PartoSure may reduce unnecessary admissions by up to R%. Values (from Di Renzo et al. 2015): X= .32 Y= .71 Z= (.32 x .71) = .2272 A= .18 B= .24 C= (.18 x .24) = .0432 R= .8098 - “Discharge” That the PartoSure test was found to be statistically superior to fFN and CL with respect to SP and PPV (P < 0.01) provides evidence toward being able to significantly enhance current practice to ultimately reduce the unnecessary administration of potentially harmful therapeutics to patients, as well as reduce the economic burden associated with unnecessary hospital admissions. “ ” 1. O’Sullivan et al. JOGS 2014 (abstract) 2. Nikolova T et al. J Perinat Med. 2015 Jan 6. [Epub ahead of print]

Clinicians Worldwide Recognize Superiority of PartoSure “ ” [PartoSure]’s most important value is in the over 70% of cases where preterm labor is false, it has helped our hospital reduce its use of Tractocile by over 75%. -Dr. Vlaemynck, AZ St. Rembert Hospital in Torhout, Belgium, 2015 “ ” PartoSure is the single most accurate test when compared to fFN and CL for prediction of imminent spontaneous delivery in patients presenting with signs, symptoms, or complaints suggestive of PTL. -Di Renzo et al. Journal Perinatal Medicine 2015 ” “ The novel bedside PAMG-1 test has a higher positive predictive value compared to other commercially available bedside tests for preterm birth such as fetal fibronectin or IGFBP-1. -Heverhagen A et al. American Journal of Obstetrics & Gynecology 2015 “ Explanation for statement, “PartoSure may reduce unnecessary admissions by up to 80%” -Assumption 1: Patient is admitted when a biomarker test alone is positive. -Assumption 2: fFN is positive X% of the time. When fFN is positive, it is incorrect Y% of the time. So, the chance of getting an unnecessary admission when relying on fFN alone is Z% (or, X% x Z%). -Assumption 3: PartoSure is positive A% of the time. When PartoSure is positive, it is incorrect B% of the time. So, the chance of getting an unnecessary admission when relying on PartoSure alone is C% (or, A% x B%). -Calculation: [1-(C/Z))=R% -Conclusion: PartoSure may reduce unnecessary admissions by up to R%. Values (from Di Renzo et al. 2015): X= .32 Y= .71 Z= (.32 x .71) = .2272 A= .18 B= .24 C= (.18 x .24) = .0432 R= .8098 ” “Although the PPV and the sensitivity of PAMG-1 are the highest, the main utility of this test, as is the measurement of cervical length, is its high negative predictive value; its prognostic capacity increases in populations with high prevalence of prematurity.” -Preterm Labor Guidelines, SEGO 2014

QUESTIONS?