From the Journals

FIGO outlines global standards for preeclampsia screening

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FIGO recommendations inconsistent with ACOG, SMFM

The recommendations regarding screening and management of first trimester preeclampsia as issued by FIGO are largely inconsistent with those from the American College of Obstetricians and Gynecologists (ACOG) and from the Society for Maternal-Fetal Medicine (SMFM), according to Baha M. Sibai, MD.

Dr. Baha M. Sibai, professor of obstetrics, gynecology, and reproductive sciences at the University of Texas, Houston

Dr. Baha M. Sibai

For example, the FIGO diagnostic criteria for preterm (prior to 37 weeks) preeclampsia – which include the presence of intrauterine growth restriction, abnormal umbilical artery Doppler, stillbirth, platelet count less than 150,000 mcL, and aspartate transaminase and alanine transaminase levels greater than 40 IU – are markedly different from those recommended by ACOG, Dr. Sibai said in an interview.

The FIGO recommendation for first trimester screening and use of low-dose aspirin at 150 mg daily starting at 13 weeks also contradicts the ACOG and SMFM recommendations, he said, noting that a 2019 ACOG practice bulletin on preeclampsia recommends 81 mg of aspirin daily initiated between 12 and 28 weeks of gestation (optimally before 16 weeks of gestation) and continuing until delivery; this is for women with any of the high risk factors for preeclampsia and for women with more than one of the moderate risk factors. Under that recommendation, more women would be eligible based on clinical risk factors. The FIGO approach is not cost effective and will miss many cases of preeclampsia, compared with the ACOG recommendations, he said.

It also should be noted that the FIGO document is funded by a grant from PerkinElmer, which markets a test for PE, he said, stressing that there are “no data suggesting that this test is valid in U.S. pregnancies.”

Dr. Sibai is a maternal-fetal medicine specialist with UT Physicians Maternal-Fetal Medicine Center–Texas Medical Center, and a professor in the department of obstetrics, gynecology, and reproductive sciences at the University of Texas Health Science Center, Houston. He was asked to comment on the article by Poon et al. He said he had no relevant financial disclosures.


 

FROM THE INTERNATIONAL JOURNAL OF GYNECOLOGY & OBSTETRICS

All pregnant women should be screened for preterm preeclampsia (PE) in the first trimester using a combined test with maternal risk factors and biomarkers as a one-step procedure, according to new recommendations from The International Federation of Gynecology and Obstetrics (FIGO).

FIGO “encourages all countries and its member associations to adopt and promote strategies to ensure [universal screening],” Liona C. Poon, MD, of Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, and colleagues wrote in a guide published in the International Journal of Gynecology & Obstetrics.

“The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI),” the authors said, noting that the baseline screening test plus a combination of maternal risk factors with MAP is an alternative when PLGF and/or UTPI can’t be measured.

The FIGO recommendations are the culmination of an initiative on PE, which involved a group of international experts convened to discuss and evaluate current knowledge on PE and to “develop a document to frame the issues and suggest key actions to address the health burden posed by PE.” Among the group’s objectives are raising awareness of the links between PE and poor outcomes, and demanding a “clearly defined global health agenda” to address the issue because preeclampsia affects 2%-5% of all pregnant women and is a leading cause of maternal and perinatal morbidity and mortality.

The recommendations represent a consensus document that provides guidance for the first trimester screening and prevention of preterm PE.

“Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of preeclampsia in singleton pregnancy,” the authors said, explaining that “[it] provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings” (Int J Gynecol Obstet. 2019;145[Suppl. 1]:1-33).

Specific suggestions are made based on region and resources, and research priorities are outlined to “bridge the current knowledge and evidence gap.”

In addition to universal first trimester screening for PE, the guide stresses a need for improved public health focus, and contingent screening approaches in areas with limited resources (including routine screening for preterm PE by maternal factors and MAP in most cases, with PLGF and UTPI measurement reserved for higher-risk women). It also recommends that women at high risk should receive prophylactic measures such as aspirin therapy beginning at 11–14+6 weeks of gestation at a dose of about 150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed.

Mary E. D’Alton, MD, a maternal-fetal medicine specialist who is chair of the department of obstetrics and gynecology and the Willard C. Rappleye Professor of Obstetrics & Gynecology at Columbia University, New York, was asked to comment on Dr. Sibai’s concerns about the guidelines. “I would simply say that ACOG and SMFM are the organizations in the United States [that] provide educational guidelines about practice in the United States.” Dr. D’Alton assisted Dr. Poon and her associates on the guidelines as an expert on preeclampsia.

Dr. Poon, given a chance to comment on the concern that the FIGO guidelines diverged from those of ACOG and SMFM, responded in an interview, “FIGO, being the global voice for women’s health, likes to ensure that our recommendations are resource appropriate. The objective of these guidelines is to provide a best practice approach, and also offers other pragmatic options for lower resource settings to ensure that preeclampsia testing can be implemented globally. We urge the broader membership of FIGO to adapt these guidelines to their local contexts.”*


She also emphasized that “PerkinElmer’s sponsorship was an unrestricted grant. The company had no involvement in writing the guideline.”*

This work was funded by an unrestricted grant from PerkinElmer, which markets an assay used for first trimester preeclampsia screening. Dr. Poon and her associates reported having no conflicts of interest.

sworcester@mdedge.com

*This article was updated 5/31/2019.

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