1. Screening for High Risk Pregnancy Peter Hornnes
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

2. Elements of antenatal care
Early, accurate determination of gestational age
Identification of the patient at risk for complications
Ongoing evaluation of health of mother and fetus
Prediction of problems, intervention when possible
Patient education, communication
But does it work?
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

3. Fiscella Obstet Gynecol 1995
14 observational studies, total sample size 670,000
11 RCTs
Prenatal care has not conclusively been demonstrated to improve birth outcomes
Policymakers deciding on funding for prenatal care must consider these findings in the context of prenatal care´s overall benefits and potential cost-effectiveness
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

4. Klerman et al Am J Public Health 2001
RCT: augmented prenatal care (N=318) consisting of educationally oriented peer groups, additional appointments, extended time with clinicians, versus controls (N=301)
Augmented care significantly increased women´s satisfaction, knowledge of risk conditions, and perceived mastery in their lives, but it did not reduce the primary outcome which was low birth weight
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

5. Villar et al Lancet 2001
27 center RCT comparing standard antenatal care (N=11,958) with a new model (N=12,568) emphasising effective actions and fewer visits
No effect on low birth weight, postpartum anemia, or urinary tract infections. Possibly higher rate of eclampsia/pre-eclampsie in new model
Conclusion: Provision of routine antenatal care by new model seemed not to affect maternal and perinatal outcomes
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

6. Antenatal care might work
Studies hampered by numerous confounding factors
Provision of antenatal care is a marker for quality in health care
Many elements in antenatal care have well documented effects
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

7. Screening for high risk pregnancy
Numerous international and national guidelines
Geographical, genetical and economical variation
Risc factor or universal approach
Individual or group antenatal care
History and physical examination, EDD
Tests for immunity and infections, blood types and hemoglobinopathies, endocrine and metabolic disorders
Ultrasound
Patient education
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

8. Screening for chromosone abnormalities
Prevention of Rhesus haemolytic diease of the fetus and newborn
Screening for preeclampsia
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

9. Screening for chromosone abnormalities
Introduced nation wide
Double test
Nuchal Translucency
Trained and certificated sonographors
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

10. Ekelund et al BMJ 2008
Retrospective study of the effects of introduction of combined first trimester screening (cFTS) at national level in 2005 and 2006
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

11. Effect of introduction of cFTS27 29 26 21 23 35 31
2007
2008
2009
2010
2011
2012
2013
2014
2015
Number of infants born with Down´s syndrome
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

12. Effect of introduction of cFTS
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

13. Screening for and prevention of Rhesus D haemolytic disease of the fetus and newborn
Postnatal screening and prophylaxis was introduced in the 1960ies resulting in a decrease of immuni-zation from 17% to 1-1.5% of Rh negative women
Bowman 1978 introduced antenatal prophylaxis causing a further reduction of immunization to 0.2% with one dose µg anti-D in week or twice 150µg in week 29 and 34
Analysis of ccfDNA allows antenatal prophylaxis targeted at the 40% that carry a D-negative foetus
Introduced nationally in DK (2010), NL (2011), FI (2014) and regionally in BE, SE, FR and UK
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

14. Dziegiel Science Series 2012
Jan 1st 2010 DK changed from postnatal to antenatal anti-D prophylaxis
RHD screening in week 25 (ccfDNA) and post-natally in cord blood, 300 µg anti-D to those found positive
Three possible outcomes of antenatal screening
Fetus is RHD positive . Anti-D is recommended
Fetus is RHD negative. Anti-D is not recommended
Assay inconclusive. Anti-D is recommended
Sensitivity 99.9%
Specificity 99.3%
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

15. Damkjær et al Vox Sang 2012 Hvidovre University Hospital in Copenhagen
Compliance with the new program after 2-5 months
90% were examined
86% of those recommended to receive anti-D were actually treated
Newer data indicate that compliance has increased
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

16. Screening for preeclampsia
Prevalence 2-3% of pregnancies
0,5% of pregnancies delivered before week 34
1 maternal mortality in DK/year
300 deliveries in DK < week 34/year
Potential treatment with aspirin from early pregnancy
How do we find the pregnant women who will develope PE?
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

17. National Institute for Health and Clinical Excellence: 1 High-Risk or 2 Mod-Risk
High-Risk factors:
Hypertensive disease in previous pregnancy
Chronic kidney disease
Autoimmune disease
Diabetes mellitus/chronic hypertension
Moderate-Risk factors
First pregnancy
Age > 40 years
Interpregnancy interval > 10 years
BMI > 35 kg/m2
Family history of PE
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

18. American College of Obstetricians and Gynecologists - ACOG
Nulliparity
Age > 40 years
BMI > 30 kg/m2
Conception by IVF
Previous pregnancy with PE
Family history of PE
Chronic hypertension
Renal disease
Diabetes mellitus
SLE
Thrombophilia
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

19. Screening by NICE or ACOG Guidelines
PE < 32 w
PE < 37 w
PE > 37 w
NICE
(FPR 10.2%)
41% (18-67)
39% (27-53)
34% (27-41)
ACOG
(FPR 64.2%)
94% (71-100)
90% (79-96)
89% (84-94)
ACOG aspirin (FPR 0.2%)
6% (1-27)
5% (2-14)
2% (0.3-5)
O`Gorman et al, Ultrasound Obstet Gynecol 2017
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

20. Estimated detection rates (%) of PE by testing with NT scan
Screening test
FPR%
PE < 34 w
Maternal characteristics 5 36
+ Ut-PI 59
+ Mean arterial blood pressure (MAP) 58
+ PAPP-A 44
+ PlGF
+ MAP + Ut-PI 80
+ Ut-PI + MAP + PAPP-A + PlGF 93
Poon and Nicolaides Obstet Gynecol Int, 2014
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

21. Observed detection rates (%) of PE by testing with NT scan
Screening test
FPR%
PE < 32 w
Maternal characteristics 10 53
+ Ut-PI 82
+ Mean arterial blood pressure (MAP) 71
+ PAPP-A 59
+ PlGF 88
+ MAP + Ut-PI 94
+ Ut-PI + MAP + PAPP-A + PlGF
100
O`Gorman et al, Ultrasound Obstet Gynecol, 2017
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

22. Early administration of low-dose aspirin
Roberge et al Fetal Diagn Ther 2012
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

23. Conclusions Screening for High Risk Pregnancy is complex and varied
Consists of very basic and very sophisticated technologies
Might appear to be quite stable but is actually evolving swiftly
Thank you for your attention
EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen

24. EBCOG TSOG Antalya May 18th 2017
Nordsjællands Hospital, University of Copenhagen