SMFM Papers

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Screening for preeclampsia using first-trimester serum

markers and uterine artery Doppler in nulliparous women
Franois Audibert, MD, MSc; Isabelle Boucoiran, MD, MSc; Na An, MD, MSc; Nikolai Aleksandrov, MD;
Edgard Delvin, MD, PhD; Emmanuel Bujold, MD, MSc; Evelyne Rey, MD, MSc
OBJECTIVE: To evaluate the screening accuracy of pregnancy hyper-

tensive disorders by maternal serum biomarkers and uterine artery

Doppler in the first trimester.
STUDY DESIGN: Prospectively enrolled nulliparous women had uterine

artery Doppler and serum measured at 11-13 weeks. Maternal characteristics, uterine artery Doppler, and serum placental biomarkers (pregnancy-associated plasma protein-A, Inhibin-A, placental protein 13,
A disintegrin and metalloprotease 12, free -hCG, placental growth
factor) were recorded.
RESULTS: Among 893 women, 20 (2.2%) had gestational hyperten-

sion developed and 40 (4.5%) had preeclampsia developed, including 9

(1.0%) early-onset preeclampsia and 16 (1.8%) severe preeclampsia.

A combined screening model with clinical characteristics, pregnancyassociated plasma protein-A, Inhibin-A, and placental growth factor
could detect 75% of early-onset preeclampsia at a 10% false-positive
rate. After adjustment for clinical variables, uterine artery Doppler, placental protein 13, and A disintegrin and metalloprotease 12 did not improve the diagnostic accuracy.
CONCLUSION: A combination of clinical characteristics and first-tri-

mester maternal serum biomarkers (pregnancy-associated plasma

protein-A, Inhibin-A, and placental growth factor) provides an accurate
screening for early-onset preeclampsia in nulliparous women.
Key words: maternal serum markers, preeclampsia, screening,
uterine artery Doppler

Cite this article as: Audibert F, Boucoiran I, An N, et al. Screening for preeclampsia using first-trimester serum markers and uterine artery Doppler in nulliparous
women. Am J Obstet Gynecol 2010;203:383.e1-8.

reeclampsia, a disease affecting

about 3% of pregnant women, contributes substantially to maternal and fetal morbidity and mortality worldwide.1
Estimating each womans individual risk
would allow appropriate antenatal surveillance, and would also enable to test
preventive strategies such as low-dose
aspirin in selected high-risk groups.2
However, the use of prophylactic treatments is likely to be more beneficial
when started earlier in pregnancy, ideally
before 16 weeks.3 It would be thus
important to develop an effective
method of early identification of highrisk groups. Currently, women at risk are

mainly identified based on clinical history. Nulliparity is one of the major clinical risk factors for the development of
preeclampsia.4 Other relevant factors
include an increased body mass index
and other medical conditions such as
prepregnancy diabetes, previous preeclampsia, or chronic hypertension.
However, screening by maternal history
alone will detect only 30% of women
who will have preeclampsia develop.5
The clinical risk-based strategy is not effective for nulliparous women without
other risk factors. The addition of maternal serum markers and uterine artery
Doppler (uAD) could improve the pre-

From the Departments of Obstetrics and Gynecology (Drs Audibert, Boucoiran, An,
Aleksandrov, and Rey) and Biochemistry (Dr Delvin), CHU Sainte-Justine Research Center,
Universit de Montral, Montreal, and the Department of Obstetrics and Gynecology (Dr
Bujold), Faculty of Medicine, Universit Laval, Qubec, QC, Canada.
Presented at the 30th Annual Meeting of the Society for Maternal-Fetal Medicine, Chicago, IL,
Feb. 1-6, 2010.
Received Feb. 26, 2010; revised May 3, 2010; accepted June 7, 2010.
Reprints not available from the authors.
Supported by a grant from the Canadian Institute of Health Research (CIHR) IHD82661. F.A. is
supported by a New Investigator Award from CIHR. I.B. is supported by a Research Award from
the Collge National des Gyncologues Obsttriciens Franais (CNGOF). E.B. is supported by a
Clinician-Scientist Award from CIHR.
0002-9378/$36.00 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.06.014

diction of the disease in this population.6,7 Several serum markers have

been suggested for first-trimester screening of preeclampsia, including free
-hCG,8 pregnancy-associated plasma
protein-A (PAPP-A),9,10 placental protein 13 (PP13),11-13 Inhibin-A,14 placental growth factor (PlGF),15 and A
disintegrin and metalloprotease 12
(ADAM12).16 Although uAD screening
has been mainly studied in the second
trimester of pregnancy,17 first-trimester
Doppler has more recently shown some
promise.18-20 A systematic review of
screening tests for preeclampsia concluded that no single test is yet available
to provide a good diagnostic accuracy.21
A combined screening involving several
relevant markers is more likely to provide the best prediction. First-trimester
screening would represent a major advantage over a second-trimester approach because it opens prospects for
early and more efficient interventions.
The aim of this study was to analyze, in a
group of nulliparous women, the diagnostic accuracy of several relevant biomarkers for the detection of subsequent
preeclampsia in the first trimester of
pregnancy, associated with maternal
characteristics and uAD.

OCTOBER 2010 American Journal of Obstetrics & Gynecology

383.e1

SMFM Papers
M ATERIALS AND M ETHODS
In this prospective cohort study, we recruited 1000 pregnant women at the time
of screening for Down syndrome at 11-13
weeks, between November 2006 and June
2008. Multiparous women, multiple gestations, and pregnancies with a major fetal
chromosomal or structural anomaly were
excluded from further analysis. Written
informed consent was obtained from all
women before enrolment in the study, and
the project was approved by the institutional ethics committee.
At the time of inclusion, women had an
interview with a research nurse and answered a standardized questionnaire on
maternal age, ethnic origin, smoking during pregnancy, and medical conditions.
The maternal weight and height were measured and the body mass index (BMI) was
calculated. An ultrasound examination
was carried out for diagnosis of major fetal
defects, measurement of nuchal translucency thickness, and crown-rump length
(CRL), which was used to determined gestational age. At the same visit both uterine
arteries were examined by transabdominal
Doppler velocimetry using a standardized
technique and performed by trained
sonographers.22 Each uterine artery was
identified by color flow mapping, at the
level of the apparent crossover with the external iliac vessels. This approach was used
because it is similar to the well-validated
second-trimester technique for uAD.
Once ensured that the angle of insonation
was less than 50 degrees, pulsed-wave
Doppler was used to cover the whole width
of the vessel. The signal was updated until
at least 6 clear similar consecutive waveforms were obtained. The pulsatility index
(PI) was measured from both uterine arteries, and we recorded the mean, lowest,
and highest PI of both sides, and the presence of a protodiastolic notch. The lowest
PI was suspected to better reflect the placental function than the mean PI, as previously described.20 The results of first trimester Doppler were not communicated
to the physicians in charge of the follow-up
and were not recorded in the ultrasound
report.
Maternal nonfasting blood samples
were collected, immediately centrifuged
for 10 minutes at 4000 rpm, divided into 4
383.e2

www.AJOG.org
aliquots, and frozen at 80oC until used
for the analyses. Free -hCG and PAPP-A
were, respectively, measured with fully
automated solid-phase, enzyme-labeled
chemiluminescent immunometric and
solid-phase, 2-site chemiluminescent immunometric assays on the IMMULITE
2000 (Siemens Medical Solutions Diagnostics, Los Angeles, CA). Total coefficients of variation (CV) were 3.8% and
6.0% at 0.4 IU/L and 4.2 IU/L for PAPP-A,
and 4.5% and 4.8% at 10 g/L and 312
g/L for free -hCG. Inhibin-A was measured by an automated 2-site chemiluminescent immunometric assay on the Access-2 (Beckman-Coulter, Chaska, MN).
Total imprecisions at 51 ng/L and 331 ng/L
were 5.9% and 4.9%, respectively.
PP13, PlGF, and ADAM12 in maternal
serum were measured with DELFIA kits
(AutoDELFIA PP13 RUO 4062-0010,
DELFIA Xpress PlGF 6007-0010, and
AutoDELFIA ADAM12 RUO 40250010, respectively) obtained from Perkin-Elmer Life and Analytical Sciences
(Turku, Finland). The total variations of
the assays were 6.6%, 4.8%, and 4.3%,
respectively. PlGF could only be measured
in 531 women, because this test was initially not scheduled and additional serum
was not available for women included in
the first year of the study.
The laboratory professionals who performed the biochemical assays were
blinded to the clinical status of subjects,
and the results were not revealed to the
clinicians, except for the first-trimester
free -hCG and PAPP-A levels, routinely
reported for Down syndrome screening.
Data on pregnancy outcomes were
collected from the hospital medical
charts. The records of all women with
hypertension were reviewed by 2 independent investigators blinded to the
first-trimester test results to determine
whether the final diagnosis was chronic
hypertension, preeclampsia, or gestational hypertension. For quality control,
we examined the records of 50 randomly
selected women without any hypertensive disorder during pregnancy. The definitions of preeclampsia and gestational
hypertension were those of the International Society for the Study of Hypertension in Pregnancy.23 Preeclampsia
was defined as resting blood pressure

American Journal of Obstetrics & Gynecology OCTOBER 2010

140/90 mm Hg on 2 occasions at least 4

hours apart and proteinuria 0.3 g/d after 20 weeks in previously normotensive
women. Gestational hypertension was
defined as hypertension in pregnancy
without proteinuria. Early-onset preeclampsia was defined as preeclampsia
diagnosed before 34 weeks. Severe preeclampsia was defined as blood pressure
160/110 mm Hg, proteinuria 5 g/d,
or the presence of an adverse condition,
including maternal symptoms, maternal
signs of end-organ dysfunction, abnormal maternal laboratory testing, or fetal
compromise, as described elsewhere.23
For statistical analysis, the following
steps were taken:
1. The women were subdivided into 3
groups depending on pregnancy outcome: preeclampsia, gestational hypertension, and unaffected by any hypertensive disorders. Cases of severe
preeclampsia and early-onset preeclampsia were separately identified
in the preeclampsia group.
2. The distributions of uAD indices and
biomarker levels were made Gaussian
after logarithmic transformation and
the normality of the distributions was
confirmed by Skewness and Kurtosis
tests.
3. We used multiple linear regressions in
the unaffected group to obtain
expected log uAD indices and biomarker levels depending on fetal CRL, maternal weight, ethnicity, and smoking as
described by Poon et al.24 Variables
were converted to multiples of the expected median (MoM) for each subject.
4. For each outcome group, uAD indices and biomarker levels expressed in
log MoM were compared by the Student t test to values of the unaffected
group. The diagnostic accuracy was
evaluated by receiver-operating characteristics (ROC) curves and area under the ROC curve (AUC).
5. The risk of preeclampsia, severe preeclampsia, and early-onset preeclampsia based on a combination of maternal
characteristic was determined by multiple logistic regression and these values
were then log10 transformed. Multiple
logistic regression analysis was then
used to analyze combinations of biomarkers and Doppler indices with

SMFM Papers

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TABLE 1

Clinical characteristics in the different groups of outcome

Variable

Unaffected
(n 833)

Gestational
hypertension
(n 20)

Severe
preeclampsia
(n 16)

Early
preeclampsia
(n 9)

Late
preeclampsia
(n 31)

Age, y, median (IQR)

29.0 (27.032.7)

26.0 (25.231.7)

30.5 (24.535.2)

32.0 (28.534.5)

30.0 (27.032.0)

BMI, kg/m , median (IQR)

22.5 (20.824.9)

26.6 (23.130.4)

26.6 (21.532.6)

28.9 (21.835.1)

27.5 (23.430.2)

................................................................................................................................................................................................................................................................................................................................................................................
2
a
b
b
a
................................................................................................................................................................................................................................................................................................................................................................................

Ethnicity, n (%)

.......................................................................................................................................................................................................................................................................................................................................................................

White

671 (80.6)

17 (85.0)

12 (75.0)

6 (66.7)

24 (77.4)

.......................................................................................................................................................................................................................................................................................................................................................................
b

Afro-Caribbean

58 (7.0)

3 (18.8)

3 (33.3)

4 (12.9)

Asian

14 (1.7)

Hispanic

23 (2.8)

2 (10.0)

1 (6.2)

1 (3.2)

Mid-Eastern

27 (3.2)

Other/mixed

40 (4.8)

1 (5.0)

2 (6.5)

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Medical history, n (%)

.......................................................................................................................................................................................................................................................................................................................................................................

None

803 (96.4)

19 (95.0)

10 (62.5)

6 (66.7)

27 (87.1)

30 (3.6)

1 (5.0)

6 (37.5)

3 (33.3)

4 (12.9)

.......................................................................................................................................................................................................................................................................................................................................................................
a
b
b

One or more

.......................................................................................................................................................................................................................................................................................................................................................................

Chronic hypertension

8 (1.0)

4 (25.0)

2 (22.2)

2 (6.5)

Diabetes type 1

4 (0.5)

Diabetes type 2

2 (0.2)

Autoimmune disease

6 (0.7)

1 (3.2)

Thrombophilia

6 (0.7)

1 (6.2)

1 (11.1)

Hyperthyroidism

1 (0.1)

1 (6.2)

1 (3.2)

Renal disease

3 (0.4)

1 (5.0)

2 (12.5)

2 (6.5)

56 (6.7)

2 (10.0)

2 (12.5)

1 (11.1)

1 (3.2)

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Smoking during pregnancy, n (%)

................................................................................................................................................................................................................................................................................................................................................................................

Medication during pregnancy, n (%)

.......................................................................................................................................................................................................................................................................................................................................................................

None

799 (96.1)

20.0 (100)

7 (43.8)

3 (33.3)

22 (71.0)

.......................................................................................................................................................................................................................................................................................................................................................................

Antihypertensive

10 (1.2)

7 (43.8)

4 (44.4)

8 (25.8)

Heparin

10 (1.2)

3 (9.7)

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Low-dose aspirin

17 (2.0)

3 (18.7)

2 (22.2)

1 (3.2)

................................................................................................................................................................................................................................................................................................................................................................................
b
a
a
a

Gestational age at delivery, wk,

median (IQR)

39.8 (38.940.7)

39.1 (37.940.0)

36.1 (34.539.0)

34.9 (33.936.4)

38.9 (37.639.5)

................................................................................................................................................................................................................................................................................................................................................................................
a
a
a

Birthweight, g, median (IQR)

3400 (30453665) 3387 (27813681)

2215 (16322869)

2000 (14652400)

3035 (27093390)

................................................................................................................................................................................................................................................................................................................................................................................

2 test for categorical variables and Mann-Whitney test for continuous variables were used to compare adverse outcome groups with unaffected group. For ethnicity, comparison is for Afro-Caribbean
vs others. All comparisons are vs unaffected group.
BMI, body mass index; IQR, interquartile range.
a

P .001; b P .05.

Audibert. Screening for preeclampsia using first-trimester serum markers and uterine artery Doppler. Am J Obstet Gynecol 2010.

maternal characteristics for the prediction of preeclampsia, severe preeclampsia, and early-onset preeclampsia. The performance of screening was
then determined by ROC curves. The
statistical software packages SPSS 16.0
(SPSS Inc, Chicago, IL) and STATA
10.0 (StataCorp, College Station, TX)
were used for data analysis. A P value
.05 was considered significant.

R ESULTS
Of 1000 consecutively enrolled
women, 107 (10.7%) were excluded
from further analysis because of multiparity (n 48), gestational age outside the inclusion criteria (n 39),
twin pregnancy (n 2), major fetal defect (n 2), miscarriage or fetal death
before 20 weeks (n 6), or missing
outcome data (n 10). Among the re-

maining 893 women, 20 had gestational hypertension (2.2%) develop,

and 40 had preeclampsia (4.5%) develop, including 9 early-onset preeclampsia (1.0%) and 31 late preeclampsia (3.5%). Sixteen women had
severe preeclampsia (1.8%). The characteristics of women are summarized
in Table 1. Women with preeclampsia
or gestational hypertension did not

OCTOBER 2010 American Journal of Obstetrics & Gynecology

383.e3

SMFM Papers

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TABLE 2

First-trimester biomarkers in the different groups of outcome

Variable

Unaffected

GH

PE

Severe PE

Early-onset PE

Inhibine-A, n 885

.......................................................................................................................................................................................................................................................................................................................................................................

Value

250.60 (184.50350.60)

226.90 (163.75328.35)

254.20 (193.70346.60)

254.20 (207.95381.85)

361.90 (218.40665.20)

.......................................................................................................................................................................................................................................................................................................................................................................

MoM

1.03 (0.761.42)

0.95 (0.771.48)

1.11 (0.791.52)

1.67a (0.962.54)

1.16 (0.761.67)

................................................................................................................................................................................................................................................................................................................................................................................

PAPP-A, n 889

.......................................................................................................................................................................................................................................................................................................................................................................

Value

2.44 (1.543.77)

1.52a (1.092.48)

1.78a (1.133.49)

1.77a (1.003.05)

2.76 (1.592.94)

MoM

1.04 (0.711.48)

0.76 (0.551.29)

0.89 (0.631.32)

0.77a (0.521.13)

0.79 (0.641.07)

.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Free -hCG, n 889

.......................................................................................................................................................................................................................................................................................................................................................................

Value

46.90 (30.8069.50)

43.80 (31.5558.80)

MoM

1.06 (0.711.52)

1.16 (0.761.56)

35.15a (25.2054.05)

35.00 (25.7071.40)

33.60 (27.6056.70)

0.82 (0.591.59)

0.83 (0.651.63)

.......................................................................................................................................................................................................................................................................................................................................................................

0.85 (0.621.51)

................................................................................................................................................................................................................................................................................................................................................................................

PP13, n 890

.......................................................................................................................................................................................................................................................................................................................................................................

Value

77.25 (58.79104.80)

63.00a (50.1484.58)

70.73 (51.0295.23)

70.36 (48.7797.83)

70.02 (49.0084.42)

1.00 (0.741.29)

1.01 (0.721.39)

0.99 (0.681.71)

.......................................................................................................................................................................................................................................................................................................................................................................

MoM

1.02 (0.771.32)

0.88 (0.691.25)

................................................................................................................................................................................................................................................................................................................................................................................

PlGF, n 531

.......................................................................................................................................................................................................................................................................................................................................................................

Value

27.57 (21.2335.56)

29.98 (18.7436.24)

23.71 (19.0133.72)

27.81a (17.3236.28)

27.81 (15.7735.99)

.......................................................................................................................................................................................................................................................................................................................................................................

MoM

0.94 (0.761.22)

1.03 (0.651.51)

0.74 (0.531.01)

0.62 (0.481.01)

0.68 (0.410.95)

................................................................................................................................................................................................................................................................................................................................................................................

ADAM12, n 888

.......................................................................................................................................................................................................................................................................................................................................................................

Value

593.00 (467.74759.00)

529.00a (385.00705.04)

545.84 (347.01726.47)

577.99 (429.25726.00)

637.88 (481.59850.20)

.......................................................................................................................................................................................................................................................................................................................................................................

MoM

0.95 (0.761.18)

0.88 (0.691.16)

1.02 (0.771.20)

0.98 (0.721.17)

1.04 (1.011.22)

................................................................................................................................................................................................................................................................................................................................................................................

Median and interquartile range for levels and MoM of biomarkers.

ADAM12, A disintegrin and metalloprotease 12; GH, gestational hypertension; MoM, median multiple of the expected median; PAPP-A, pregnancy-associated plasma protein-A; PE, preeclampsia;
PIGF, placental growth factor; PP13, placental protein 13.
a

P .05 (t test, compared with unaffected group).

Audibert. Screening for preeclampsia using first-trimester serum markers and uterine artery Doppler. Am J Obstet Gynecol 2010.

differ from those in the unaffected

group for maternal age and smoking
status. The BMI at enrollment was significantly higher in women with preeclampsia or gestational hypertension than
in unaffected women (P .01).
Early-onset preeclampsia was more likely

to occur in Afro-Caribbean women and in

women with a preexisting medical condition (P .05).
In the unaffected group, all biomarkers were significantly correlated to gestational age (except PP13) and to BMI (except PlGF). None was correlated to

maternal age. PlGF (1.39 vs 1.00; P

.001), ADAM12 (1.21 vs 0.98; P .012),
and PAPP-A (1.37 vs 0.97; P .001) levels differed significantly between AfroCaribbean women and others. They also
differed significantly between smokers
and nonsmokers for PlGF (1.25 vs 0.98;

TABLE 3

Uterine artery Doppler findings in the different groups of outcome

PI, median (interquartile range)
Lowest

Outcome

Bilateral
notching,
n (%)

PI value

MoM

PI value

MoM

PI value

MoM

Unaffected

289 (36.5)

1.06 (0.791.48)

1.00 (0.741.36)

1.40 (1.051.78)

1.10 (0.821.39)

1.69 (1.222.18)

1.01 (0.731.28)

13 (35.1)

1.13 (0.731.55)

1.02 (0.681.53)

1.57 (1.181.76)

1.24 (0.941.39)

1.81 (1.392.19)

1.06 (0.861.28)

Severe PE

5 (33.3)

1.48 (0.631.91)

1.36 (0.581.72)

1.59 (0.831.98)

1.27 (0.711.45)

1.81 (1.042.06)

1.06 (0.661.25)

Early-onset PE

3 (37.5)

1.48 (0.551.74)

1.37 (0.541.62)

1.58 (0.821.78)

1.28 (0.701.38)

1.65 (1.111.92)

1.00 (0.691.12)

10 (34.5)

1.10 (0.791.49)

1.01 (0.731.42)

1.57 (1.211.78)

1.24 (0.991.48)

1.92 (1.472.24)

1.15 (0.881.34)

6 (30.0)

1.14 (0.851.90)

1.10 (0.801.75)

1.28 (1.082.16)

1.10 (0.871.66)

1.46 (1.272.24)

0.88 (0.771.38)

Mean

Highest

................................................................................................................................................................................................................................................................................................................................................................................

PE

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Late PE

................................................................................................................................................................................................................................................................................................................................................................................

GH

................................................................................................................................................................................................................................................................................................................................................................................

GH, gestational hypertension; MoM, multiples of the median, adjusted for gestational age at measurement; PE, preeclampsia; PI, pulsatility index.
Audibert. Screening for preeclampsia using first-trimester serum markers and uterine artery Doppler. Am J Obstet Gynecol 2010.

383.e4

American Journal of Obstetrics & Gynecology OCTOBER 2010

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TABLE 4

Area under ROC curve (95% confidence interval) of biomarkers

and uterine artery Doppler for the diagnosis of preeclampsia,
severe preeclampsia, and early-onset preeclampsia
Variable

Preeclampsia

Severe preeclampsia

Early-onset preeclampsia

PAPP-A

0.570 (0.4820.657)

0.661 (0.5560.766)

0.622 (0.4760.767)

ADAM12

0.500 (0.4110.589)

0.531 (0.4140.648)

0.420 (0.2350.604)

PlGF

0.654 (0.5210.787)

0.711 (0.5410.882)

0.747 (0.5090.984)

Free -hCG

0.548 (0.4530.643)

0.560 (0.4250.696)

0.510 (0.2850.736)

Inhibin-A

0.546 (0.4500.642)

0.569 (0.4340.704)

0.708 (0.4950.922)

PP13

0.517 (0.4270.608)

0.514 (0.3910.638)

0.483 (0.2710.695)

M-PI

0.553 (0.4620.643)

0.584 (0.4400.728)

0.482 (0.2710.694)

L-PI

0.515 (0.4130.618)

0.601 (0.4450.757)

0.529 (0.2750.784)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

cantly different between cases and controls. Bilateral notching frequency was
also similar between groups.
The AUC for all biomarkers and
Doppler results is shown in Table 4. The
best predictors of early-onset preeclampsia were PlGF, Inhibin-A, and
PAPP-A (AUC of 0.75, 0.71, and 0.62,
respectively). Table 5 shows the AUC of
various combinations of clinical characteristics, biomarkers, and Doppler findings. The sensitivity and likelihood ratios
of the same combinations at a fixed
screen-positive rate of 10% are shown in
Table 6.

..............................................................................................................................................................................................................................................

ADAM12, A disintegrin and metalloprotease 12; L-PI, lowest of uterine artery Doppler pulsatility indices; M-PI, mean of uterine
artery Doppler pulsatility indices; PAPP-A, pregnancy-associated plasma protein-A; PlGF, placental growth factor; PP13,
placental protein 13.
Audibert. Screening for preeclampsia using first-trimester serum markers and uterine artery Doppler. Am J Obstet
Gynecol 2010.

P .015), ADAM12 (0.81 vs 1.01; P

.001), PAPP-A (0.87 vs 1.02; P .001),
and free -hCG (0.78 vs 1.01; P .002).
Table 2 shows the levels of biomarkers
according to the pregnancy outcome.
Compared with unaffected women,
those who had severe preeclampsia develop had lower levels of PAPP-A (median MoM, 0.77) and PlGF (median
MoM, 0.62), and women with subsequent early-onset preeclampsia had

higher levels of Inhibin-A (median

MoM, 1.67). MoMs of free -hCG,
PP13, and ADAM12 did not differ significantly between groups.
Table 3 shows the results of uAD. Linear regression analysis in the unaffected
group demonstrated that log PI was independently predicted by fetal CRL but
not by ethnic origin, maternal BMI, and
age. First-trimester lowest, mean, and
highest uAD PI MoMs were not signifi-

C OMMENT
The findings of this prospective study in
nulliparous women have confirmed
some results of previous studies that
first-trimester low levels of maternal serum PAPP-A8-10,25,26 and PlGF,15,27-29
and increased levels of serum InhibinA14,30 are associated with an increased
risk for subsequent development of preeclampsia. The levels are more altered in
women having early or severe preeclampsia develop rather than late and
mild preeclampsia. We also confirmed
that women with increased BMI and
women of Afro-Caribbean ethnicity are
at higher risk of hypertensive disorders

TABLE 5

Area under the ROC curve (95% confidence interval) for different combinations of maternal
characteristics, serum analytes, and uterine artery Doppler at 11-13 weeks gestation
Characteristic

Preeclampsia

Severe preeclampsia

Early-onset preeclampsia

Maternal characteristics alone

0.750 (0.6670.832)

0.780 (0.6700.890)

0.756 (0.5540.949)

................................................................................................................................................................................................................................................................................................................................................................................

Maternal characteristics plus:

.......................................................................................................................................................................................................................................................................................................................................................................

L-PI

0.746 (0.6590.834)

0.789 (0.6790.899)

0.738 (0.5290.946)

PlGF

0.790 (0.7020.878)

0.786 (0.6450.926)

0.847 (0.5931.000)

PAPP-A

0.742 (0.6580.827)

0.797 (0.7020.892)

0.780 (0.6240.937)

Inhibin-A

0.754 (0.6770.830)

0.793 (0.7020.883)

0.841 (0.7030.980)

PlGF, PAPP-A

0.795 (0.7100.880)

0.814 (0.6950.933)

0.844 (0.5841.000)

PlGF, Inhibin A

0.794 (0.7130.876)

0.815 (0.6900.941)

0.958 (0.8771.000)

PAPP-A, Inhibin A

0.742 (0.6600.824)

0.809 (0.7150.904)

0.851 (0.7140.989)

PlGF, Inhibin-A, PAPP-A

0.793 (0.7140.873)

0.851 (0.7490.953)

0.969 (0.9101.000)

Inhibin, PAPP-A, L-PI

0.745 (0.6600.829)

0.814 (0.7120.916)

0.834 (0.6830.986)

PlGF, Inhibin-A, PAPP-A, L-PI

0.815 (0.7370.893)

0.890 (0.8030.977)

0.994 (0.9821.000)

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

L-PI, lowest of uterine artery Doppler pulsatility indices; PAPP-A, pregnancy-associated plasma protein-A; PlGF, placental growth factor.
Audibert. Screening for preeclampsia using first-trimester serum markers and uterine artery Doppler. Am J Obstet Gynecol 2010.

OCTOBER 2010 American Journal of Obstetrics & Gynecology

383.e5

SMFM Papers

www.AJOG.org

TABLE 6

Sensitivity and positive likelihood ratio of different combinations of maternal characteristics, PlGF, PAPP-A,
Inhibin-A, and uterine artery Doppler at 11-13 weeks gestation, for a fixed 10% false-positive rate
Preeclampsia

Severe preeclampsia

Variable

Sensitivity

LR

Maternal characteristics alone

30.0

3.0

Early-onset preeclampsia

LR

Sensitivity

LR

0.78

45.5

4.5

LR

0.60

Sensitivity
55.6

LR

LR

5.6

0.49

................................................................................................................................................................................................................................................................................................................................................................................

Maternal characteristics plus:

.......................................................................................................................................................................................................................................................................................................................................................................

L-PI

35.1

3.5

0.72

42.1

4.2

0.64

50.0

5.0

0.55

PlGF

40.9

4.1

0.66

61.5

6.1

0.43

75.0

7.5

0.28

PAPP-A

32.5

3.2

0.75

54.5

5.4

0.50

55.6

5.6

0.49

Inhibin-A

35.0

3.5

0.72

50.0

5.0

0.55

55.6

5.6

0.49

PlGF, PAPP-A

40.9

4.1

0.66

53.8

5.4

0.51

75.0

7.5

0.28

PlGF, Inhibin-A

40.9

4.1

0.66

53.8

5.4

0.51

75.0

7.5

0.28

PAPP-A, Inhibin-A

32.5

3.2

0.75

54.5

5.5

0.50

55.6

5.6

0.49

PlGF, Inhibin-A, PAPP-A

31.8

3.2

0.76

53.8

5.4

0.51

75.0

7.5

0.28

Inhibin, PAPP-A, L-PI

32.4

3.2

0.75

52.6

5.3

0.53

37.5

3.7

0.69

PlGF, Inhibin-A, PAPP-A, L-PI

40.0

4.0

0.67

54.5

5.5

0.50

100.0

10.0

0.00

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

All models including PlGF are based on 531 women only, including 498 unaffected, 22 with preeclampsia (13 severe, 4 early-onset).
L-PI, lowest of uterine artery Doppler pulsatility indices; LR, likelihood ratio for a positive test; PAPP-A, pregnancy-associated plasma protein-A; PlGF, placental growth factor.
Audibert. Screening for preeclampsia using first-trimester serum markers and uterine artery Doppler. Am J Obstet Gynecol 2010.

of pregnancy. However, we did not confirm the predictive accuracy of other

candidates such as PP13, ADAM12, and
free -hCG. In addition, although we did
find an association between abnormal
first-trimester uAD and subsequent preeclampsia, we found that the addition
of Doppler did not improve the diagnostic accuracy of screening by clinical characteristics alone or combined with
PAPP-A, PlGF, and Inhibin-A.
The strengths of this study include its
prospective design, which examines a
large number of biomarkers in the same
cohort, associated with clinical characteristics and uAD. All tests were performed in the first trimester at a single
visit, at the time of Down syndrome
screening by nuchal translucency and serum markers. Another interest of the
current study is that we studied only nulliparous women, whereas, most previous
studies have also enrolled multiparous
women. The clinical use of preeclampsia
screening in low-risk multiparous women
is limited, given the very low likelihood of
preeclampsia in this population. On the
other hand, screening in high-risk multiparas (eg, previous preeclampsia) may
also be of limited clinical value, because
preventive treatment and increased sur383.e6

veillance is recommended in this population. Another important aspect is the

inclusion of maternal characteristics
such as maternal age, BMI, and ethnicity
in the prediction model. In agreement
with Poon et al,31 we found that such
factors are important predictors of hypertensive disorders in pregnancy in nulliparous women. A good diagnostic accuracy was provided by a combination of
clinical characteristics and serum levels
of PAPP-A, PlGF, and Inhibin-A, with
sensitivity of 75% for a 10% false-positive rate. Although the complete model,
including Doppler, provided a theoretic
100% sensitivity for the detection of
early-onset preeclampsia, these results
should be taken with caution because of
the small number of early-onset cases
and the poor accuracy of Doppler alone.
It has been suggested that ideally, a predictive test for preeclampsia should have
a very high positive likelihood ratio (LR)
15 and very low negative LR 0.1.32 In
the current study, most positive LR are in
the range of 37. This performance is
lower than in 1 previous study,7 and the
next step is to confirm its validity in
larger cohorts before recommending its
implementation in clinical practice.33
This approach also provides opportuni-

American Journal of Obstetrics & Gynecology OCTOBER 2010

ties to design large prospective trials of

prevention in women screened at high
risk. Preventive treatments such as lowdose aspirin are more efficient when initiated early in pregnancy and when used
in women identified at high-risk based
mainly on prior adverse pregnancy outcome.3 We are not aware of any randomized trial that evaluated such preventive
treatment in women screened at highrisk with a combination of factors in the
first trimester of pregnancy.
In the current study, the predictive accuracy of PP13, ADAM12, and free
-hCG was poor compared with previous studies.11,13,16 Nicolaides et al11
found that a combination of PP13 and
uAD in the first trimester could provide a
90% detection rate of early preeclampsia, for a 9% false-positive rate, using an
ELISA assay with a pair of PP13 specific
monoclonal antibodies. More recently,
the same group of investigators, using
the same technique and reagents as in the
current study, found that PP13 did not
significantly improve the prediction of
early preeclampsia provided by a combination of maternal factors, uterine artery
PI, and PAPP-A.34 A potential explanation for these conflicting results could be
that different techniques were used. We

SMFM Papers

www.AJOG.org
used an automated assay, whereas, previous reports used a manual assay and a
specific monoclonal antibody. To our
knowledge, a direct comparison of both
methods is currently not available, and
these conflicting reports call for further
studies. Another limitation of earlier
studies with PP13 is that serum levels
were not adjusted to maternal weight
and other relevant clinical factors. Given
the strong association between maternal
weight and PP13 levels, and the fact that
increased BMI is a strong predictor of
subsequent preeclampsia, it is of paramount importance to adjust maternal
levels to weight or BMI when analyzing
this marker for the prediction of
preeclampsia.
The reasons of the discordant results of
first trimester uAD and the discrepancy
with previous studies remain elusive. Several recent studies have found markedly
increased PI of the uterine arteries in the
first trimester in women with subsequent
early-onset preeclampsia.19,24,35 In our
study, we did find increased PI in the affected groups, but the diagnostic accuracy
was poor compared with previous studies.
All measurements were performed by 4
trained sonographers and physicians, all
experienced in ultrasound and Doppler.
Procedures were standardized at the initiation of the study and all measurements
were recorded on a computerized database
and reviewed for quality control. The only
technical difference that we can find between the current study and other reports
was the site of sampling of the uterine arteries, at the crossing of external iliac vessels in our study, and at the level of the internal cervical os in others.19 Interestingly,
the median value of uterine artery PI observed in the unaffected group was 1.40 in
the current cohort and 1.63 in the study by
Poon et al24 (P .01). Another study using
the paracervical approach found mean PI
indexes of 1.6-1.8 at 11-13 weeks in an unselected population,36 whereas, in the
study by Baschat et al, using the same technique as the current study, the mean PI was
close to 1.40 in unaffected women. The
comparison of the diagnostic accuracy obtained with different sampling sites of the
uterine arteries in the first trimester requires further studies, ideally a direct prospective comparison.

The current study was limited by the

relatively small number of affected
women, especially for early-onset
cases. Also, PlGF levels were only available in half of the cohort, including
only 4 women with early-onset preeclampsia, thus limiting the power of
the study to analyze the predictive accuracy of this marker, alone or in combination. Despite this limitation, we
found low levels of PlGF among all
groups of preeclamptic women, and
the addition of PlGF did improve the
screening models, although comparisons did not reach statistical significance. Another limitation of this study
is that the mean arterial pressure
(MAP) was not recorded at the time of
inclusion. It has been recently suggested that MAP in the first trimester is
an important component of early
screening models for preeclampsia.24,37 The inclusion of MAP in our
models might have increased the
screening performance, and this
readily available parameter should
probably be part of any future screening model for preeclampsia. Several
women (2% of the cohort) were treated
with low-dose aspirin (80 mg daily
started in the first trimester) for various indications. However, the exclusion of these women did not change
significantly the main results of the
study.
In conclusion, our data confirmed the
efficacy of first-trimester screening for
preeclampsia in nulliparous women, using a combination of maternal characteristics and serum markers. The prediction model does not necessarily require
uAD to reach a good sensitivity and is
particularly accurate at predicting subsequent early or severe preeclampsia, are
associated with the most significant maternal and neonatal morbidity. Controlled trials should now test preventive
treatments, such as low-dose aspirin in
selected groups of nulliparous women
screened at risk for preeclampsia in the
first trimester.
f
ACKNOWLEDGMENTS
We are grateful to Tarja Ahola and Pasi Kankaanp (Perkin Elmer) for providing the assay
services and for their comments.

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