Antiplatelet Agents and the Prevention of

Spontaneous Preterm Birth

A Systematic Review and Meta-analysis
Presenter: Dr. Roza Maulindra
Moderator: Dr. H. Wim T Pangemanan, SpOG(K)

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
DR. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
 Background
Preterm birth is one of the most challenging obstetric
problems worldwide approximately 512% of all
deliveries
affects 2-3% of all pregnancies.
Traditional screening for preeclampsia: identify risk factors
from maternal demographic characteristics and medical
history
The performance of such an approach, which essentially
treats each risk factor as a separate screening test with
additive detection rate (DR) and screen positive rate, has
not been evaluated.
 Bayes theorem
An alternative approach screening allows
estimation of individual patient-specific risks of
preeclampsia that require delivery before a
specified gestation
combine the a priori risk from maternal
characteristics and medical history with the
results of various combinations of biophysical
and biochemical
OBJECTIVE

The purpose of this study was to develop a model for

preeclampsia based on maternal demographic
characteristics and medical history
METHODS

120.492 singleton pregnancies

in women who attended their routine first hospital

visit pregnancy at University College London
Hospital, Kings College Hospital, and Medway
Maritime Hospital, United Kingdom.
 The women were screened between January 2006
and March 2014

In this visit, at 11+0 13+6 weeks gestation,

recorded maternal characteristics and medical
history and performed combined screening for
aneuploidies

Gestational age was determined by the

measurement of fetal crown-rump length at 11-13
weeks gestation
 Inclusion criteria:
singleton pregnancy undergoing first trimester
combined screening for aneuploidy
a phenotypically normal live birth or stillbirth at or
after 24 weeks gestation
 Exclusion Ciretria
pregnancies with aneuploidies and major fetal abnormalities
pregnancies ending in termination
miscarriage, or fetal death at <24 weeks gestation.
RESULT
Comment
Screening for preeclampsia by maternal
characteristics and obstetric history is associated
with a higher DR for a given FPR,
if the maternal factors are combined into a
multivariable logistic model rather than treating
each one as an independent screening test as
recommended by NICE.
 The new model can predict 40%, 48%, and 54% of cases of
preeclampsia at any gestation and preeclampsia that requires
delivery at <37 and at <34 weeks gestation, respectively, which
is higher than the respective values of 35%, 40%, and 44%,
respectively than NICE
 In the new model, increased risk for preeclampsia
provided by :
Advancing maternal age
Increasing weight,
Afro-Caribbean and South Asian racial origin
Medical history of chronic hypertension,
diabetes mellitus
systemic lupus erythematosus or antiphospholipid
syndrome,
family history and personal history of preeclampsia,
conception by in vitro fertilization.
 The risk for preeclampsia decreases with
Increasing maternal height and in parous women with no previous
preeclampsia
which is related inversely to the interpregnancy interval, persists
>15 years
 The main benefit of our method is that it provides a pre- vious
model that can be used in conjunction with likelihood ratios from
bio-physical and biochemical markers to derive patient-specific
risks for preeclampsia that is developing at any desired
gestational age cutoff.
 We previously reported that screening at 11-13 weeks gestation
by a combination of maternal factors (can predict 54%, 77%,
and >90% of cases of preeclampsia at any gestation and
preeclampsia that requires delivery at <37 and at<34 weeks
gestation, respectively, at FPR of 10%.
 The major strengths of the study are :

prospective examination of a large number of pregnancies

in which specific questions were asked to identify known
factors that are associated with preeclampsia,

the use of multivariable survival analysis to identify the

factors and define their contribution in the prediction of
preeclampsia,

The development of a survival-time model that allows the

estimation of individual patient-specific risks of
preeclampsia that will require delivery before any specified
gestation.
 A limitation of the study is :
The performance of screening by a model that is derived and
tested with the use of the same dataset is overestimated.
 COMPARASION
Screening by the NICE or World Health Organization guidelines
involves dichotomization of continuous measurements,

whereas, our study has demonstrated that the observed

proportions of preeclampsia depend continuously on maternal
age, weight, height, and interpregnancy interval that is
captured poorly by this process of dichotomization.

Consequently, in our model these factors are treated as

continuous rather than categoric variables.
 Additionally, in previous scoring systems patients were classified as screen
positive and screen negative for preeclampsia based on the presence or
absence of specific characteristics each one of which was attributed the
same independent importance.
In our model, the risk factors were combined through a multivariate
survival-time model that allows estimation of individual patient risk for
preeclampsia at any desired gestational age cutoff or prespecified time
interval from assessment.
Critical Appraisal
Is the study in paper youve read using
survei or registration data?
Induction vs deduction how this paper
explain these ?
Variabel scale, explain this papers
varables
Type of Variabel: dependent vs
independent, explain what are them in
this paper
This paper using registration data of
maternal visite at 11+0 13+6 weeks
gestation
This paper using induction method to
reach its conclusion
They are nominal (eq: race, medical
hystory), categorical (eq: parous,
conception), and interval data (almost
all variabel convert into interval data)
Dependent: risk of preeclampsia
Independent: maternal demographic,
gestational age, medical history,
conception, smoking, family history, etc
Type of Data: primer, secunder, tersier, Using primary data from direct
explain about this paper type of data measurement of maternal visite

Group vs Individual data, explain about this Using individual data of each patients
papers type of data

Routine vs ad hoc data, explain about this Ad hoc data

papers type of data

Central, variation, position measurement They are using central and variation
variable, explain about this papers variables measurement
Master table, distribution table, crosstab
table. Explain about this papers table data
Graph: hystogram, ogive, stem & leaf, box-
plot, bar, line, scatter. Explain about this
papers graph
Explain about this papers Quality data
conclusion
Bias, explain about this papers bias
The table has been explained
previously
This paper mainly using box plot
graphic
It has 95% confidence intreval
performance of screening by a model
that is derived and tested with the use
of the same dataset is overestimated
Explain about this Papers number of They purposively selecting all patients
sample for estimation and hypotetical within time periode in 3 hospital which
test are meet the inclusion criteria (120492)

Explain about this paper randomization There is no randomisation

sampling technique: simple, sisstematic,
stratification, claster ?
Statistic technique used in this paper Distribution, comparation, regression, ROC

Explain about this paper statitical analysis No statistical analysis fraud founded
/ practice fraud
Explain wheter there are mistaken in No conclusion mistaken noted
conclude the statistical analysis result

How they presented biostatistic They present writtenly

analysis riset or vital registration,
naratively / written ?
Did they used media to present No media used
biostatistic analysis riset?
Thank You