{"id":2908,"date":"2019-11-14T01:09:15","date_gmt":"2019-11-14T01:09:15","guid":{"rendered":"http:\/\/cms.firststepmart.com\/?p=2908"},"modified":"2019-11-24T20:09:50","modified_gmt":"2019-11-24T20:09:50","slug":"2908","status":"publish","type":"post","link":"https:\/\/fetalradiology.co.in\/?p=2908","title":{"rendered":"Samrakshan:  Rationale for universal 1st trimester screening to identify pregnant women at risk for preterm preeclampsia"},"content":{"rendered":"\n<p><strong>Authors<\/strong>: Rijo M Choorakuttil, Palanisamy Devarajan, Bavaharan  Rajalingam,  Neelam Jain, Lalit K Sharma, Shweta Nagar, Akanksha Baghel, Neeraj Gupta, J.P. Chouhan, Ramesh S Shenoy, Praveen K Nirmalan for the Samrakshan Team. <\/p>\n\n\n\n<p><strong>Running Title:<\/strong> 1<sup>st<\/sup> Trimester screening and preterm PE <\/p>\n\n\n\n<p><strong>Author\nAffiliations<\/strong><\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>Rijo M Choorakuttil, National Coordinator for Samrakshan IRIA, AMMA Center for Diagnosis and Preventive Medicine, Kochi, Kerala, India&nbsp; <\/li><li>Palanisamy Devarajan, Nethra Scans and Genetic Clinic,      Tiruppur, Tamil Nadu, India <\/li><li>Rajalingam Bavaharan, Fetocare Magnum Imaging and Diagnostics, Trichy, Tamil Nadu, India <\/li><li>Neelam Jain, Jain Ultrasound centre, C-112, B block , Dispensary road&nbsp; Sonari, Jamshedpur Jharkhand, India<\/li><li>Lalit K Sharma, Raj Sonography &amp; X- Ray Clinic, Baiju Choraha, Nayapura, Guna, Madhya Pradesh, India<\/li><li>Shweta Nagar, Dr. Shweta Nagar\u2019s Ultrasound Clinic &amp; Imaging Centre, Flat no. 101, Princes Center, above Mama Loca cafe , 6\/3 New Palasia, Indore, Madhya Pradesh, India<\/li><li>Akanksha Baghel, Baghel Sonography Center. Front of Janpat Office, near District Hospital, Harda, Madhya Pradesh,&nbsp; India<\/li><li>Neeraj Gupta, Neeraj Diagnostic And Imaging Center, near Surya hotel, South Tokoganj, Indore, Madhya Pradesh, India <\/li><li>J. P. Chouhan, Purnima Hospital and Research Center, 74, Narmada Marg, Barwaha, Khargone, Madhya Pradesh, India<\/li><li>Ramesh S Shenoy,&nbsp; Consultant Radiologist, Lisie Hospital, Ernakulam, Kerala, India <\/li><li>Praveen K Nirmalan, Chief Research Mentor, AMMA ERF, AMMA Center for Diagnosis and Preventive Medicine, Kochi, Kerala, India&nbsp; <\/li><\/ol>\n\n\n\n<p><strong>Corresponding\nAuthor:<\/strong> Rijo M Choorakuttil, National Coordinator\nfor Samrakshan IRIA, AMMA Center for Diagnosis and Preventive Medicine, Kochi,\nKerala, India. E-mail: <a href=\"mailto:rijomc@gmail.com\">rijomc@gmail.com<\/a> &nbsp;&nbsp;<\/p>\n\n\n\n<p><em>Key words<\/em>: Pregnancy, 1<sup>st<\/sup> trimester,&nbsp; screening, pre eclampsia, India<\/p>\n\n\n\n<p>Samrakshan, a\nnationwide program of the Indian Radiological &amp; Imaging Association (IRIA) launched\nin June 2019,&nbsp; aims to optimize the\nexperience and expertise of radiologists in India to supplement and complement\nexisting efforts that address perinatal mortality in India. &nbsp;Samrakshan aims at a pragmatic approach\ncognizant of local realities and flexible that it can be adopted by many rather\nthan a few. &nbsp;<\/p>\n\n\n\n<p>Pre-eclampsia (PE)\nand Fetal Growth Restriction (FGR) are the conditions of interest for\nSamrakshan. These conditions are important health problems in India as judged\nby its frequency and severity. The epidemiology, incidence, prevalence and\nnatural history of these two conditions are reasonably understood from latent\nto declared disease and there is robust evidence about the association between\nseveral risk factors and the risk of serious or treatable disease.<\/p>\n\n\n\n<p>The National\nFamily Health Survey-4 (NFHS-4), a nationally representative survey carried out\nin 2015-16 in India, reported a perinatal mortality rate of 36 per 1000\npregnancies. [1] The perinatal mortality rate ranged from 8 per 1,000\npregnancies in Kerala to 56 per 1,000 pregnancies in Uttar Pradesh.[1] NFHS-4\nreported a still birth rate of 0.7% and a neonatal mortality rate of 30 per\n1000 live births in India, and a birth weight &lt;2500 grams in 18.2% of live\nbirths.[1]&nbsp; A major proportion (41.77%)\nof neonatal deaths in India is attributable to prematurity and low birth\nweight.[2] The maternal mortality ratio in India has declined and is reported\nas 130 per 100,000 live births in 2014-16. [3] Pregnancy induced hypertension\nremains a major cause for maternal mortality, preterm deliveries, fetal growth\nrestriction and low birth weight in India.&nbsp;&nbsp;\n<\/p>\n\n\n\n<p>The NFHS-4\nreported an increasing utilization of antenatal care (ANC) with 82.7% pregnant\nwomen reporting at least one antenatal care visit, however, only 58.6% women in\nthe 1st trimester of pregnancy sought antenatal care.[1] Although an estimated\n79% of all deliveries were institutional deliveries, only 61% of all\npregnancies had received at least one ultrasound exam during pregnancy.[1]&nbsp;&nbsp; <\/p>\n\n\n\n<p>In this\nmanuscript, we discuss the protocol and the rationale of the 1<sup>st<\/sup> trimester\nopportunistic screening implemented through the Samrakshan program launched by\nIRIA, with a specific focus on PE . <\/p>\n\n\n\n<p><strong>Definitions<\/strong><\/p>\n\n\n\n<p>Standardizing\nmeasures and harmonizing definitions are integral to the long term success of screening\nprograms. These allow comparisons with other programs and approaches and\nreplication on a larger scale. The definition of PE and Pregnancy Induced\nHypertension (PIH) is thus important. Samrakshan endorses the definition of PE\nand PIH [4] proposed by the International Society for the Study of Hypertension\nin Pregnancy (ISSHP). <\/p>\n\n\n\n<p><strong>Gestational\nhypertension<\/strong> is defined as persistent hypertension\n(systolic blood pressure &nbsp;\u2265140&nbsp;mm&nbsp;Hg and\/or diastolic blood\npressure &nbsp;\u226590&nbsp;mm&nbsp;Hg after\n20&nbsp;weeks of gestation in the absence of features of PE. [4]\n\n\n\n<p>The ISSHP defines <strong>PE<\/strong>\n[4] as a systolic blood pressure at \u2265140&nbsp;mm&nbsp;Hg and\/or diastolic blood\npressure at \u226590&nbsp;mm&nbsp;Hg on at least two occasions measured 4&nbsp;hours\napart in previously normotensive women <strong><em>and<\/em><\/strong> is accompanied by one\nor more of the following new\u2010onset conditions <strong><em>at or after<\/em> <\/strong>20&nbsp;weeks\nof gestation:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Proteinuria <ul><li>&nbsp;\u226530&nbsp;mg\/mol protein: creatinine ratio<\/li><\/ul><ul><li>\u2265300&nbsp;mg\/24&nbsp;hour <\/li><\/ul><ul><li>or \u22652&nbsp;+&nbsp;dipstick<\/li><\/ul><\/li><li>Evidence of other maternal\norgan dysfunction<ul><li>Acute kidney injury (creatinine\n\u226590&nbsp;\u03bcmol\/L; 1&nbsp;mg\/dL)<\/li><\/ul><ul><li>Liver involvement (elevated\ntransaminases, e.g. alanine aminotransferase or aspartate aminotransferase\n&gt;40&nbsp;IU\/L) with or without right upper quadrant or epigastric abdominal\npain<\/li><\/ul><ul><li>Neurological complications\n(e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe\nheadaches, and persistent visual scotomata) <\/li><\/ul><ul><li>or Haematological complications\n(thrombocytopenia\u2013platelet count &lt;150&nbsp;000\/\u03bcL, disseminated\nintravascular coagulation, haemolysis)<\/li><\/ul><ul><li>Uteroplacental dysfunction <ul><li>Fetal growth restriction, <\/li><\/ul><ul><li>Abnormal umbilical artery Doppler waveform analysis<\/li><\/ul><ul><li>or Stillbirth <\/li><\/ul><\/li><\/ul><\/li><\/ul>\n\n\n\n<p>PE can be classified\ninto four, not necessarily mutually exclusive, categories:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Early\u2010onset PE (with delivery\nat &lt;34+0&nbsp;weeks of gestation)<\/li><li>Preterm PE (with delivery at\n&lt;37+0&nbsp;weeks of gestation)<\/li><li>Late\u2010onset PE (with delivery at\n\u226534+0&nbsp;weeks of gestation)<\/li><li>Term PE (with delivery at\n\u226537+0&nbsp;weeks of gestation)<\/li><\/ul>\n\n\n\n<p><strong>Superimposed<\/strong> <strong>PE<\/strong> on chronic hypertension is considered when women with\nchronic essential hypertension develop any of the above maternal organ\ndysfunctions consistent with pre\u2010eclampsia.[4] Increase in blood pressure in\nitself is not sufficient to diagnose superimposed PE. In the absence of\npre\u2010existing proteinuria, new\u2010onset proteinuria in the setting of a rise in\nblood pressure is sufficient to diagnose superimposed PE. <\/p>\n\n\n\n<p><strong>Measurement<\/strong> <strong>of<\/strong> <strong>Blood<\/strong> <strong>Pressures<\/strong><\/p>\n\n\n\n<p><em>Instrumentation<\/em><\/p>\n\n\n\n<p>Samrakshan\nrecommends the use of validated digital automated or semi automated oscillometry\nmachines to measure BP. Samrakshan recommends calibrating the machines at least\nonce every 3-4 months. The use of digital oscillometry machines are recommended\nfor several reasons that include<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Consistency with global\nprotocols for the measurement of Blood pressure as part of trimester specific\nscreening protocols for PE<\/li><li>Environmental concerns with the\nuse of mercury sphygmomanometer <\/li><li>Availability and Affordability\nof Digital oscillometry machines to measure BP. These are now available on\nonline shopping portals.<\/li><\/ul>\n\n\n\n<p>Method to measure\nBP [5]\n\n\n\n<p>The woman should\nbe seated with their arms well supported at the level of their heart and an\nappropriate\u2010sized adult cuff (small &lt;22&nbsp;cm, normal 22\u201332&nbsp;cm, or\nlarge 33\u201342&nbsp;cm) used depending on the mid\u2010arm circumference. After rest\nfor 5&nbsp;minutes, blood pressure is measured in both arms simultaneously and\ntwo sets of recordings are made at 1\u2010minute intervals. As a pragmatic\nrecommendation, &nbsp;BP maybe measured in one\narm and two recordings are made at 1\u2010minute intervals.&nbsp;The four sets of systolic\nBP and diastolic BP measurements are then used to determine the Mean Arterial\nPressure (MAP) using the following equation: <\/p>\n\n\n\n<p>MAP= diastolic BP + (systolic BP-diastolic BP)\/3.<\/p>\n\n\n\n<p>The 4 sets of\nsystolic and diastolic BP measures are input into the risk calculator and the\nfinal MAP measurement (average of four sets of measurements) is determined. <\/p>\n\n\n\n<p><strong>Measurement<\/strong> <strong>of<\/strong> <strong>Uterine<\/strong> <strong>Artery<\/strong> <strong>PI<\/strong> [6]\n\n\n\n<p><em>Route<\/em>: &nbsp;A transabdominal ultrasound\nscan is preferred although a transvaginal approach can also be used. &nbsp;<\/p>\n\n\n\n<p><em>Applicable GA\nrange<\/em>: &nbsp;11+0&nbsp;to 13+6&nbsp;weeks of gestation\n(corresponding to fetal crown\u2013rump length (CRL) of 42\u201384&nbsp;mm). Gestational\nage must be determined from the measurement of the fetal CRL.<\/p>\n\n\n\n<p><em>Measurements<\/em> <em>of<\/em> <em>Uterine<\/em> <em>Artery<\/em> <em>PI<\/em>: Samrakshan recommends\nthe use of a standardized protocol, as advised by the Fetal Medicine Foundation\nand the International Society of Ultrasound in Obstetrics and Gynaecology [6]\nand quoted below. <\/p>\n\n\n\n<p>\u201cObtain a sagittal\nsection of the uterus is obtained and identify the cervical canal and internal\ncervical os. Keep the transducer in the midline and gently tilted to the side\nand use colour flow mapping to identify each uterine artery along the side of\nthe cervix and uterus at the level of the internal os. Use Pulsed\u2010wave Doppler\nwith the sampling gate set at 2&nbsp;mm to cover the whole vessel. Take care to\nensure that the angle of insonation is less than 30\u00b0. The uterine artery PI (UTPI)\nis measured when three similar consecutive waveforms are obtained and the mean\nUTPI of the left and right arteries is calculated\u201d<\/p>\n\n\n\n<p>The measurement of\nUTPI at the level of the internal os during the first trimester is more\nreproducible and can be achieved in a greater proportion of women than those\nobtained at the level of the crossover of the external iliac vessels.&nbsp;[7]\n\n\n\n<p><em>Additional<\/em> <em>Information<\/em> <em>from<\/em> <em>same<\/em> <em>test<\/em>: The same\nscan is utilized for the measurement of fetal translucency thickness and\ndiagnosis of any major fetal defects<\/p>\n\n\n\n<p><strong>The<\/strong> <strong>Screening<\/strong> <strong>Protocol<\/strong> <\/p>\n\n\n\n<p>Applicable\nGestational Age<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Gestational Age 11-13+6 weeks<\/li><\/ul>\n\n\n\n<p>Unique ID<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Assign each woman an unique ID\nthat can be used to track progress and to document findings through the course\nof the pregnancy. <\/li><\/ul>\n\n\n\n<p>Assign an expected\ndate of delivery (EDD)<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Ask the LMP of the woman. Please\nremember to explain to the woman that LMP is calculated from the 1<sup>st<\/sup>\nday of the last menstrual period<\/li><li>Do a dating scan (if not done\nearlier)<\/li><li>Measure Fetal Crown Rump Length<\/li><li>Check for discrepancy in the EDD\nbased on LMP and USG<\/li><li>Assign an EDD <\/li><li>Do not change the assigned EDD\nlater during the course of the pregnancy. If the assigned EDD is changed,\ndocument clearly the reasons for the change <\/li><\/ul>\n\n\n\n<p>Clinico-Demographic\nDetails<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Maternal Age in years<\/li><li>Maternal Height in centimetres<\/li><li>Maternal Weight in kilograms<\/li><li>Ethnicity of the mother: Asian\nIndian\/ Mixed<\/li><\/ul>\n\n\n\n<p>Past Obstetric\nHistory <\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Parity nulliparous, parous\nwithout prior PE, parous with prior PE<\/li><li>Interpregnancy interval in\nyears between the birth of the last child <\/li><li>Gestational age at previous\nchildbirth\/delivery (weeks)<\/li><li>Birthweight of previous\npregnancy beyond 24&nbsp;weeks <\/li><\/ul>\n\n\n\n<p>Family History<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Family history of PE (mother)<\/li><\/ul>\n\n\n\n<p>Current Conception<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Method of conception: spontaneous,\novulation induction, in vitro fertilization<\/li><\/ul>\n\n\n\n<p>Personal Risk\nBehaviour: <\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Smoking habit (mark yes if\ntobacco consumption is there in any form- ask for oral chewable forms of\ntobacco)<\/li><\/ul>\n\n\n\n<p>Co\nmorbidities:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>History of chronic hypertension<ul><li>History of diabetes mellitus:\ntype 1, type 2, insulin intake<\/li><\/ul><ul><li>History of systemic lupus\nerythematosus or antiphospholipid syndrome<\/li><\/ul><\/li><\/ul>\n\n\n\n<p>Blood Pressure Measures\n<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Systolic BP in both arms<\/li><li>Diastolic BP in both arms<\/li><li>Enter BP in the online risk\ncalculator available online at <a href=\"https:\/\/fetalmedicine.org\/research\/assess\/preeclampsia\/first-trimester\">https:\/\/fetalmedicine.org\/research\/assess\/preeclampsia\/first-trimester<\/a><\/li><li>Estimate MAP using online\ncalculator <\/li><\/ul>\n\n\n\n<p>Doppler Measures<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Measure Right Uterine Artery PI<\/li><li>Measure Left Uterine Artery PI <\/li><li>Estimate Mean Uterine Artery PI\n<\/li><\/ul>\n\n\n\n<p><strong>Biochemical<\/strong> <strong>Markers: <\/strong>Placental Growth Factor (PLGF) [8] and\/or Pregnancy\nAssociated Plasma Protein A (PAPP-A) [9] are biochemical markers that improve\nthe detection rate of pregnant women at high risk for the development of\npreterm PE. <\/p>\n\n\n\n<p>Samrakshan\nacknowledges that these tests are not widely available, accessible or\naffordable for the larger population of pregnant women in India. As a pragmatic\nmeasure, Samrakshan recommends that these tests may be done where possible but\ndoes not mandate the use of these tests. <\/p>\n\n\n\n<p><strong>Elements of the\nscreening protocol<\/strong><\/p>\n\n\n\n<p>Each of the risk\nfactors in the screening protocol are based on prior evidence for the\nassociation of these risk factors with PE [10-14] and hence we are not going\ninto a detailed description, in this manuscript, of the association of the\ncomponents of the screening protocol&nbsp;\nwith onset of PE.<\/p>\n\n\n\n<p><strong>The rationale\nof choosing this screening protocol<\/strong><\/p>\n\n\n\n<p>In routine\nclinical practice, a common approach to determine the risk of PE is based on maternal\ndemographics and medical history pertaining to maternal risk factors. [15-18] The\nNational Institute for Health and Clinical Excellence (NICE) in the UK, issued\nrecommendations that women should be considered to be at high risk of\ndeveloping PE if they have any one high\u2010risk factor (hypertensive disease in\nprevious pregnancy, chronic hypertension, chronic renal disease, diabetes\nmellitus, or autoimmune disease) or any two moderate\u2010risk factors (nulliparity,\nage \u226540&nbsp;years, BMI \u226535&nbsp;kg\/m2, family history of PE, or interpregnancy\ninterval &gt;10&nbsp;years).[12] In the USA, the American College of\nObstetricians and Gynecologists (ACOG) recommended daily low\u2010dose aspirin\nstarting from the late first trimester for women with a history of early\u2010onset\nPE and preterm delivery at less than 34&nbsp;weeks of gestation, or for women\nwith more than one prior pregnancy complicated by PE. [19] However, the\ndetection rate is 39% for preterm PE and 34% for term PE at 10.3% false\u2010positive\nrate on screening using the NICE guidelines [20] and 90% and 89%, at 64.3%\nfalse\u2010positive rate using the US guidelines.[21]\n\n\n\n<p>The identification\nof four potentially useful biomarkers a) MAP, b) Uterine Artery Doppler studies\nc) PAPP A and d) PLGF has improved the effectiveness of screening protocols for\nPE. &nbsp;The detection rates of preterm PE\nand term PE improved to 75% and 43%, respectively, at false\u2010positive rate of\n10% with the use of these biomarkers. [22,23]\n\n\n\n<p>The screen\u2010positive\nrate by the NICE method was 10.3%, the detection rate for all PE was 30%, and\nfor preterm PE it was 41% in a recent study by the National Institute for\nHealth Research (UK) that prospectively looked at validating the Bayesian based\ncompeting risk models that form the basis of the screening protocol Samrakshan\nis adopting. [24] The detection rate of the mini\u2010combined test (maternal\nfactors, MAP, and PAPP\u2010A) for all PE was 43% and was superior to that of the\nNICE method by 12.1% (95% CI, 7.9\u201316.2). [24] In screening for preterm PE by a\ncombination of maternal factors, MAP, UTPI, and PLGF, the detection rate was\n82%, which was higher than that of the NICE method by 41.6% (95% CI,\n33.2\u201349.9). [24]\n\n\n\n<p><strong>What does\nSamrakshan recommend as the screening protocol?<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Samrakshan recommends a risk\u2010based\nscreening for preterm PE using various biomarkers based on the available global\nevidence.&nbsp;<\/li><li>Current evidence indicates that\na checklist approach based on maternal history and risk factors alone is no\nlonger sufficient to identify pregnant women at high risk for preterm PE.<\/li><li>The competing risk Bayesian\nbased algorithm or model has a higher detection rate. <\/li><li>The detection rates of preterm\nPE will be reduced in the absence of biochemical biomarkers, PLGF, however, currently\nit is a pragmatic reality in India that biochemical biomarkers have to be\noptional given issues with affordability, accessibility and availability.<\/li><li>Samrakshan recommends a\nparadigm shift to a one step 1<sup>st<\/sup> trimester screening including MAP\nand Uterine Artery PI Doppler studies for all pregnant women at 11-13+6 weeks<\/li><li>Samrakshan considers a woman as\nhigh risk when the risk is 1 in 150 or more based on the first\u2010trimester\ncombined test with maternal risk factors, MAP, and UTPI.<\/li><li>&nbsp;Samrakshan recommends screening in the 1<sup>st<\/sup>\ntrimester as an evidence based prophylactic intervention (low dose aspirin at 150mg\nonce daily at bedtime) &nbsp;can be provided\nto pregnant women identified as at high risk for preterm PE until 36&nbsp;weeks\nof gestation, &nbsp;or when delivery occurs,\nor when PE is diagnosed.[25] The prophylactic benefits of low dose aspirin will\nbe discussed in a separate manuscript. <\/li><\/ul>\n\n\n\n<p>References<\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>International\n     Institute for Population Sciences (IIPS) and ICF. 2017. National Family\n     Health Survey (NFHS-4) 2015-16: India. Mumbai: IIPS&nbsp;<\/li><li>Million\n     Death Study Collaborators, Bassani DG, Kumar R, et al. Causes of neonatal\n     and child mortality in India: a nationally representative mortality\n     survey.&nbsp;Lancet. 2010; 376:1853\u20131860.&nbsp;<\/li><li>Niti\n     Ayog, India. Maternal Mortality Ratio (per 100,000 live births). Accessed\n     online from <a href=\"https:\/\/www.niti.gov.in\/content\/maternal-mortality-ratio-mmr-100000-live-birth\">https:\/\/www.niti.gov.in\/content\/maternal-mortality-ratio-mmr-100000-live-births<\/a>, on September 2, 2019<\/li><li>Brown\n     MA,&nbsp;Magee LA,&nbsp;Kenny LC, et&nbsp;al.&nbsp;The hypertensive\n     disorders of pregnancy: ISSHP classification, diagnosis &amp; management\n     recommendations for international practice.&nbsp;Pregnancy\n     Hypertens.&nbsp;2018;&nbsp;13:&nbsp;291\u2013&nbsp;310.<\/li><li>Poon\n     LC,&nbsp;Zymeri NA,&nbsp;Zamprakou A,&nbsp;Syngelaki A,&nbsp;Nicolaides\n     KH.&nbsp;Protocol for measurement of mean arterial pressure at\n     11\u201013&nbsp;weeks\u2019 gestation.&nbsp;Fetal Diagn\n     Ther.&nbsp;2012;&nbsp;31:&nbsp;42\u2013&nbsp;48.<\/li><li>Sotiriadis\n     A,&nbsp;Hernandez\u2010Andrade E,&nbsp;da Silva Costa F, et&nbsp;al.&nbsp;ISUOG\n     Practice Guidelines: Role of ultrasound in screening for and follow\u2010up of\n     pre\u2010eclampsia.&nbsp;Ultrasound Obstet\n     Gynecol.&nbsp;2019;&nbsp;53:&nbsp;7\u2013&nbsp;22.<\/li><li>Lefebvre J,&nbsp;Demers\nS,&nbsp;Bujold E, et&nbsp;al.&nbsp;Comparison of two different sites of\nmeasurement for transabdominal uterine artery Doppler velocimetry at\n11\u201013&nbsp;weeks.&nbsp;Ultrasound Obstet Gynecol.&nbsp;2012;40:288\u2013292.<\/li><li>Zhong Y,&nbsp;Zhu F,&nbsp;Ding\nY.&nbsp;Serum screening in first trimester to predict pre\u2010eclampsia, small for\ngestational age and preterm delivery: Systematic review and\nmeta\u2010analysis.&nbsp;BMC Pregnancy Childbirth.&nbsp;2015;15:191.<\/li><li>Morris RK, Bilagi A, Devani P,\nKilby MD. 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Chouhan, Ramesh S Shenoy, Praveen K Nirmalan for the Samrakshan Team. Running Title: 1st Trimester screening and preterm PE Author Affiliations Rijo M Choorakuttil, National Coordinator for Samrakshan IRIA, AMMA Center for Diagnosis and Preventive [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[14],"tags":[],"class_list":["post-2908","post","type-post","status-publish","format-standard","hentry","category-original-article"],"_links":{"self":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/2908","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2908"}],"version-history":[{"count":8,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/2908\/revisions"}],"predecessor-version":[{"id":3058,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/2908\/revisions\/3058"}],"wp:attachment":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2908"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2908"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2908"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}