Preeclampsia screening evidence report and systematic review for the US preventive services task force

Jillian T. Henderson, Jamie H. Thompson, Brittany U. Burda, Amy Cantor

Research output: Contribution to journalReview article

25 Citations (Scopus)

Abstract

IMPORTANCE Preeclampsia is a complex disease of pregnancy with sometimes serious effects on maternal and infant morbidity and mortality. It is defined by hypertension after 20 weeks' gestation and proteinuria or other evidence of multisystem involvement. OBJECTIVE To systematically review the benefits and harms of preeclampsia screening and risk assessment for the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, and Cochrane Central Register of Controlled Trials databases from 1990 through September 1, 2015. Surveillance for new evidence in targeted publications was conducted through October 5, 2016. STUDY SELECTION English-language trials and observational studies, including externally validated prediction models, of screening effectiveness, benefits, and harms from routine preeclampsia screening during pregnancy. DATA EXTRACTION AND SYNTHESIS Independent dual review of article abstracts and full texts against a priori inclusion criteria. Meta-analysis was not performed because of clinical and statistical heterogeneity of included studies. MAIN OUTCOMES AND MEASURES Maternal and infant health outcomes, including eclampsia, stroke, stillbirth, preterm birth, and low birthweight; screening and risk prediction test performance; harms of screening and risk assessment. RESULTS Twenty-one studies (13 982 participants) were included. No studies directly compared the effectiveness of preeclampsia screening in a screened population vs an unscreened population; 1 US trial (n = 2764) found no difference in benefits or harms with fewer prenatal visits but was underpowered for rare, serious outcomes. For harms, a before-after comparison cohort noninferiority study of urine protein screening for specific indications compared with routine screening (n = 1952) did not identify harms with fewer urine screening tests. Four studies (n = 7123) reported external validation performance of 16 risk prediction models, 5 of which had good or better discrimination (c statistic >0.80) for prediction of preeclampsia, and positive predictive values of 4%in the largest, most applicable validation cohorts. Calibration was not reported despite being a key model performance measure. There were no studies of urine screening test performance conducted in asymptomatic primary care populations; 14 studies of protein urine test performance among women being evaluated for suspected preeclampsia (n = 1888) had wide-ranging test accuracy (sensitivity, 22%-100%; specificity, 36%-100%) and high statistical and clinical heterogeneity in tests used, eligibility criteria, and proteinuria prevalence (8.7%-93.8%). CONCLUSIONS AND RELEVANCE Evidence to estimate benefits and harms of preeclampsia screening and the test performance of different screening approaches over the course of pregnancywas limited. Externally validated risk prediction models had limited applicability and lacked calibration and clinical implementation data needed to support routine use. Further research is needed to better inform risk-based screening approaches and improve screening strategies, given the complex pathophysiology and clinical unpredictability of preeclampsia.

Original languageEnglish (US)
Pages (from-to)1668-1683
Number of pages16
JournalJAMA - Journal of the American Medical Association
Volume317
Issue number16
DOIs
StatePublished - Apr 25 2017

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Advisory Committees
Pre-Eclampsia
Urine
Proteinuria
Pregnancy
Calibration
Population
Eclampsia
Stillbirth
Premature Birth
Infant Mortality
PubMed
MEDLINE
Observational Studies
Publications
Meta-Analysis
Primary Health Care
Proteins
Cohort Studies
Language

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Preeclampsia screening evidence report and systematic review for the US preventive services task force. / Henderson, Jillian T.; Thompson, Jamie H.; Burda, Brittany U.; Cantor, Amy.

In: JAMA - Journal of the American Medical Association, Vol. 317, No. 16, 25.04.2017, p. 1668-1683.

Research output: Contribution to journalReview article

Henderson, Jillian T. ; Thompson, Jamie H. ; Burda, Brittany U. ; Cantor, Amy. / Preeclampsia screening evidence report and systematic review for the US preventive services task force. In: JAMA - Journal of the American Medical Association. 2017 ; Vol. 317, No. 16. pp. 1668-1683.
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abstract = "IMPORTANCE Preeclampsia is a complex disease of pregnancy with sometimes serious effects on maternal and infant morbidity and mortality. It is defined by hypertension after 20 weeks' gestation and proteinuria or other evidence of multisystem involvement. OBJECTIVE To systematically review the benefits and harms of preeclampsia screening and risk assessment for the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, and Cochrane Central Register of Controlled Trials databases from 1990 through September 1, 2015. Surveillance for new evidence in targeted publications was conducted through October 5, 2016. STUDY SELECTION English-language trials and observational studies, including externally validated prediction models, of screening effectiveness, benefits, and harms from routine preeclampsia screening during pregnancy. DATA EXTRACTION AND SYNTHESIS Independent dual review of article abstracts and full texts against a priori inclusion criteria. Meta-analysis was not performed because of clinical and statistical heterogeneity of included studies. MAIN OUTCOMES AND MEASURES Maternal and infant health outcomes, including eclampsia, stroke, stillbirth, preterm birth, and low birthweight; screening and risk prediction test performance; harms of screening and risk assessment. RESULTS Twenty-one studies (13 982 participants) were included. No studies directly compared the effectiveness of preeclampsia screening in a screened population vs an unscreened population; 1 US trial (n = 2764) found no difference in benefits or harms with fewer prenatal visits but was underpowered for rare, serious outcomes. For harms, a before-after comparison cohort noninferiority study of urine protein screening for specific indications compared with routine screening (n = 1952) did not identify harms with fewer urine screening tests. Four studies (n = 7123) reported external validation performance of 16 risk prediction models, 5 of which had good or better discrimination (c statistic >0.80) for prediction of preeclampsia, and positive predictive values of 4{\%}in the largest, most applicable validation cohorts. Calibration was not reported despite being a key model performance measure. There were no studies of urine screening test performance conducted in asymptomatic primary care populations; 14 studies of protein urine test performance among women being evaluated for suspected preeclampsia (n = 1888) had wide-ranging test accuracy (sensitivity, 22{\%}-100{\%}; specificity, 36{\%}-100{\%}) and high statistical and clinical heterogeneity in tests used, eligibility criteria, and proteinuria prevalence (8.7{\%}-93.8{\%}). CONCLUSIONS AND RELEVANCE Evidence to estimate benefits and harms of preeclampsia screening and the test performance of different screening approaches over the course of pregnancywas limited. Externally validated risk prediction models had limited applicability and lacked calibration and clinical implementation data needed to support routine use. Further research is needed to better inform risk-based screening approaches and improve screening strategies, given the complex pathophysiology and clinical unpredictability of preeclampsia.",
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N2 - IMPORTANCE Preeclampsia is a complex disease of pregnancy with sometimes serious effects on maternal and infant morbidity and mortality. It is defined by hypertension after 20 weeks' gestation and proteinuria or other evidence of multisystem involvement. OBJECTIVE To systematically review the benefits and harms of preeclampsia screening and risk assessment for the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, and Cochrane Central Register of Controlled Trials databases from 1990 through September 1, 2015. Surveillance for new evidence in targeted publications was conducted through October 5, 2016. STUDY SELECTION English-language trials and observational studies, including externally validated prediction models, of screening effectiveness, benefits, and harms from routine preeclampsia screening during pregnancy. DATA EXTRACTION AND SYNTHESIS Independent dual review of article abstracts and full texts against a priori inclusion criteria. Meta-analysis was not performed because of clinical and statistical heterogeneity of included studies. MAIN OUTCOMES AND MEASURES Maternal and infant health outcomes, including eclampsia, stroke, stillbirth, preterm birth, and low birthweight; screening and risk prediction test performance; harms of screening and risk assessment. RESULTS Twenty-one studies (13 982 participants) were included. No studies directly compared the effectiveness of preeclampsia screening in a screened population vs an unscreened population; 1 US trial (n = 2764) found no difference in benefits or harms with fewer prenatal visits but was underpowered for rare, serious outcomes. For harms, a before-after comparison cohort noninferiority study of urine protein screening for specific indications compared with routine screening (n = 1952) did not identify harms with fewer urine screening tests. Four studies (n = 7123) reported external validation performance of 16 risk prediction models, 5 of which had good or better discrimination (c statistic >0.80) for prediction of preeclampsia, and positive predictive values of 4%in the largest, most applicable validation cohorts. Calibration was not reported despite being a key model performance measure. There were no studies of urine screening test performance conducted in asymptomatic primary care populations; 14 studies of protein urine test performance among women being evaluated for suspected preeclampsia (n = 1888) had wide-ranging test accuracy (sensitivity, 22%-100%; specificity, 36%-100%) and high statistical and clinical heterogeneity in tests used, eligibility criteria, and proteinuria prevalence (8.7%-93.8%). CONCLUSIONS AND RELEVANCE Evidence to estimate benefits and harms of preeclampsia screening and the test performance of different screening approaches over the course of pregnancywas limited. Externally validated risk prediction models had limited applicability and lacked calibration and clinical implementation data needed to support routine use. Further research is needed to better inform risk-based screening approaches and improve screening strategies, given the complex pathophysiology and clinical unpredictability of preeclampsia.

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