Clinical Standards Committee:
The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scientific organization that encourages sound clinical practice, and high-quality teaching and research related to diagnostic imaging in women's healthcare. The ISUOG Clinical Standards Committee (CSC) has a remit to develop Practice Guidelines and Consensus Statements as educational recommendations that provide healthcare practitioners with a consensus-based approach, from experts, for diagnostic imaging. They are intended to reflect what is considered by ISUOG to be the best practice at the time at which they are issued. Although ISUOG has made every effort to ensure that Guidelines are accurate when issued, neither the Society nor any of its employees or members accepts any liability for the consequences of any inaccurate or misleading data, opinions or statements issued by the CSC. The ISUOG CSC documents are not intended to establish a legal standard of care, because interpretation of the evidence that underpins the Guidelines may be influenced by individual circumstances, local protocol and available resources. Approved Guidelines can be distributed freely with the permission of ISUOG (info@isuog.org).

https://obgyn.onlinelibrary.wiley.com/doi/pdfdirect/10.1002/uog.22134

ISUOG Practice Guidelines: diagnosis and management of small‐for‐gestational‐age fetus and fetal growth restriction

Hypertensive disorders of pregnancy affect up to 10% of pregnancies worldwide, which includes the 3%–5% of all pregnancies complicated by preeclampsia. Preeclampsia is defined as new onset hypertension after 20 weeks’ gestation with evidence of maternal organ or uteroplacental dysfunction or proteinuria. Despite its prevalence, the risk factors that have been identified lack accuracy in predicting its onset and preventative therapies only moderately reduce a woman’s risk of preeclampsia. Preeclampsia is a major cause of maternal morbidity and is associated with adverse foetal outcomes including intra-uterine growth restriction, preterm birth, placental abruption, foetal distress, and foetal death in utero. At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent, due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and frequency at which assessments should be conducted. Current management of the foetus in preeclampsia involves timely delivery and prevention of adverse effects of prematurity with antenatal corticosteroids and/or magnesium sulphate depending on gestation. Alongside the risks to the foetus during pregnancy, there is also growing evidence that preeclampsia has long-term adverse effects on the offspring. In particular, preeclampsia has been associated with cardiovascular sequelae in the offspring including hypertension and altered vascular function.

https://www.mdpi.com/2077-0383/8/10/1625/pdf

Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring.

Pre-eclampsia and fetal growth restriction arise from disorders of placental development and have some shared mechanistic features. Initiation is often rooted in the maldevelopment of a maternal–placental blood supply capable of providing for the growth requirements of the fetus in later pregnancy, without exerting undue stress on maternal body systems. Here, we review normal development of a placental bed with a safe and adequate blood supply and a villous placenta–blood interface from which nutrients and oxygen can be extracted for the growing fetus. We consider disease mechanisms that are intrinsic to the maternal environment, the placenta or the interaction between the two. Systemic signalling from the endocrine placenta targets the maternal endothelium and multiple organs to adjust metabolism for an optimal pregnancy and later lactation. This signalling capacity is skewed when placental damage occurs and can deliver a dangerous pathogenic stimulus. We discuss the placental secretome including glycoproteins, microRNAs and extracellular vesicles as potential biomarkers of disease. Angiomodulatory mediators, currently the only effective biomarkers, are discussed alongside non-invasive imaging approaches to the prediction of disease risk. Identifying the signs of impending pathology early enough to intervene and ameliorate disease in later pregnancy remains a complex and challenging objective. Pre-eclampsia and fetal growth restriction are diseases of pregnancy that arise from disorders of placental development. This Review discusses healthy development of the placenta and considers disease mechanisms, biomarkers and diagnosis of pre-eclampsia and fetal growth restriction.

Tracking placental development in health and disease.

Preeclampsia, a systemic vascular disorder characterized by new-onset hypertension and proteinuria after 20 weeks of gestation, is the leading cause of maternal and perinatal morbidity and mortality. Maternal endothelial dysfunction caused by placental factors has long been accepted with respect to the pathophysiology of preeclampsia. Over the past decade, increased production of placental antiangiogenic factors has been identified as a placental factor leading to maternal endothelial dysfunction and systemic vascular dysfunction. This review summarizes the recent advances in understanding the molecular mechanisms of endothelial dysfunction caused by placental antiangiogenic factors, and the novel clinical strategies based on these discoveries.

https://www.mdpi.com/1422-0067/20/17/4246/pdf

Preeclampsia: Maternal Systemic Vascular Disorder Caused by Generalized Endothelial Dysfunction Due to Placental Antiangiogenic Factors

Imbalances in circulating angiogenic factors in the pathophysiology of preeclampsia and related disorders

Placental growth factor testing to assess women with suspected pre-eclampsia: a multicentre, pragmatic, stepped-wedge cluster-randomised controlled trial

Hypertension affects 10% of pregnant women, and approximately 3% of singleton pregnancies are complicated by preeclampsia. Preeclampsia often presents ambiguously, and the risks for women with suspected preeclampsia are complex. Angiogenic factors, such as placental growth factor (PlGF), are associated with the pathophysiology of preeclampsia. Studies have shown that detection of low circulating maternal PlGF concentrations has a 96% sensitivity and 98% negative predictive value in diagnosing preeclampsia that required delivery within 14 days in women with suspected preeclampsia. However, the effectiveness of PlGF testing has not been examined in a real-world setting. Therefore, the researchers sought to determine whether circulating PlGF concentration, along with a clinical management algorithm, would lower the clinical time needed to diagnose women with suspected preeclampsia or whether this approach reduced adverse maternal or perinatal outcomes. The researchers performed a multicenter, pragmatic, stepped-wedge cluster-randomized controlled trial in 11 maternity units in the United Kingdom, each responsible for 3000 to 9000 deliveries per year. Inclusion criteria for the study were women 18 years and older presenting with suspected preeclampsia between 20 + 0 weeks and 36 + 6 weeks of gestation with a live, singleton fetus.Women identified at routine antenatal appointments or following acute clinical presentation with symptoms were included in the trial, whereas women with a documented diagnosis of preeclampsia at presentation were ineligible. Health, Inc. All rights reserved. 577 Obstetrical Complications Suspected preeclampsia was defined as new-onset or worsening of existing hypertension, dipstick proteinuria, epigastric or right upper-quadrant pain, headache with visual disturbances, fetal growth restriction, or abnormal maternal blood tests that were suggestive of disease (such as thrombocytopenia or hepatic or renal dysfunction). Primary outcome was time from presentation with suspected preeclampsia to documented preeclampsia for women in the trial who received that diagnosis. For the study period between June 13, 2016 and October 27, 2017, 1035women with suspected preeclampsia were enrolled in the trial; 1023 of these women met eligibility criteria. Of these, 576 women (56%) were assigned to the intervention group (testing revealed), and 447 women (44%) were assigned to receive their usual care with additional concealed testing. Three women in the first group were lost during follow-up, leaving 573 women in the revealed testing group; one woman in the concealed testing group withdrew consent, leaving 446 women in the concealed testing group. In the concealed testing group, the mean time to preeclampsia diagnosis was 4.1 days, whereas in the revealed testing group, it was 1.9 days. Severe maternal adverse outcomes were reported in 24 (5%) of the 447 women in the concealed testing group and in 22 (4%) of the 573 women in the revealed testing group (adjusted odds ratio, 0.32; 95% confidence interval [CI], 0.11–0.96; P = 0.043), whereas there was no evidence of difference in perinatal adverse outcomes (15% vs 14%; adjusted odds ratio, 1.45; CI, 0.73–2.90) or gestational age at delivery (36.6 vs 36.8 weeks; mean difference, 0.52; 95% CI, 0.63–0.73). The researchers concluded that revealing PlGF test results substantially reduced the time to confirm a suspected preeclampsia diagnosis. In patients where PlGF testing was revealed, there was a lower incidence of maternal adverse outcomes, consistent with surveillance of these patients and as recommended in the management algorithm. The authors suggest that their data support PlGF testing in women with suspected preeclampsia as a diagnostic adjunct.

Placental Growth Factor Testing to Assess Women With Suspected Preeclampsia: A Multicenter, Pragmatic, Stepped-Wedge Cluster-Randomized Controlled Trial

Jessica Lowe

Papers

Placental growth factor testing to assess women with suspected pre-eclampsia: a multicentre, pragmatic, stepped-wedge cluster-randomised controlled trial

Placental Growth Factor Testing to Assess Women With Suspected Preeclampsia: A Multicenter, Pragmatic, Stepped-Wedge Cluster-Randomized Controlled Trial