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Validation and development of models using clinical, biochemical and ultrasound markers for predicting pre-eclampsia: an individual participant data meta-analysis

Allotey, John, Laivuori, Hannele, Snell, Kym IE, Smuk, Melanie, Hooper, Richard, Chan, Claire L, Ahmed, Asif, Chappell, Lucy C, von Dadelszen, Peter, Dodds, Julie, Green, Marcus, Kenny, Louise, Khalil, Asma, Khan, Khalid S, Mol, Ben W, Myers, Jenny, Poston, Lucilla, Thilaganathan, Basky, Staff, Anne C, Smith, Gordon CS, Ganzevoort, Wessel, Odibo, Anthony O, Ramírez, Javier A, Kingdom, John, Daskalakis, George, Farrar, Diane, Baschat, Ahmet A, Seed, Paul T, Prefumo, Federico, da Silva Costa, Fabricio, Groen, Henk, Audibert, Francois, Masse, Jacques, Skråstad, Ragnhild B, Salvesen, Kjell Å, Haavaldsen, Camilla, Nagata, Chie, Rumbold, Alice R, Heinonen, Seppo, Askie, Lisa M, Smits, Luc JM, Vinter, Christina A, Magnus, Per M, Eero, Kajantie, Villa, Pia M, Jenum, Anne K, Andersen, Louise B, Norman, Jane E, Ohkuchi, Akihide, Eskild, Anne, Bhattacharya, Sohinee, McAuliffe, Fionnuala M, Galindo, Alberto, Herraiz, Ignacio, Carbillon, Lionel, Klipstein-Grobusch, Kerstin, Yeo, SeonAe, Teede, Helena J, Browne, Joyce L, Moons, Karel GM, Riley, Richard D, Thangaratinam, Shakila·2020·Health Technology Assessment
DOI 10.3310/hta24720
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Abstract

Background: Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk is needed to plan management. Objectives: To assess the performance of existing pre-eclampsia prediction models and to develop and validate models for pre-eclampsia using individual participant data meta-analysis. We also estimated the prognostic value of individual markers. Design: This was an individual participant data meta-analysis of cohort studies. Setting: Source data from secondary and tertiary care. Predictors: We identified predictors from systematic reviews, and prioritised for importance in an international survey. Primary outcomes: Early-onset (delivery at < 34 weeks’ gestation), late-onset (delivery at ≥ 34 weeks’ gestation) and any-onset pre-eclampsia. Analysis: We externally validated existing prediction models in UK cohorts and reported their performance in terms of discrimination and calibration. We developed and validated 12 new models based on clinical characteristics, clinical characteristics and biochemical markers, and clinical characteristics and ultrasound markers in the first and second trimesters. We summarised the data set-specific performance of each model using a random-effects meta-analysis. Discrimination was considered promising for C-statistics of ≥ 0.7, and calibration was considered good if the slope was near 1 and calibration-in-the-large was near 0. Heterogeneity was quantified using I 2 and τ 2. A decision curve analysis was undertaken to determine the clinical utility (net benefit) of the models. We reported the unadjusted prognostic value of individual predictors for pre-eclampsia as odds ratios with 95% confidence and prediction intervals. Results: The International Prediction of Pregnancy Complications network comprised 78 studies (3,570,993 singleton pregnancies) identified from systematic reviews of tests to predict pre-eclampsia. Twenty-four of the 131 published prediction models could be validated in 11 UK cohorts. Summary C-statistics were between 0.6 and 0.7 for most models, and calibration was generally poor owing to large between-study heterogeneity, suggesting model overfitting. The clinical utility of the models varied between showing net harm to showing minimal or no net benefit. The average discrimination for IPPIC models ranged between 0.68 and 0.83. This was highest for the second-trimester clinical characteristics and biochemical markers model to predict early-onset pre-eclampsia, and lowest for the first-trimester clinical characteristics models to predict any pre-eclampsia. Calibration performance was heterogeneous across studies. Net benefit was observed for International Prediction of Pregnancy Complications first and second-trimester clinical characteristics and clinical characteristics and biochemical markers models predicting any pre-eclampsia, when validated in singleton nulliparous women managed in the UK NHS. History of hypertension, parity, smoking, mode of conception, placental growth factor and uterine artery pulsatility index had the strongest unadjusted associations with pre-eclampsia. Limitations: Variations in study population characteristics, type of predictors reported, too few events in some validation cohorts and the type of measurements contributed to heterogeneity in performance of the International Prediction of Pregnancy Complications models. Some published models were not validated because model predictors were unavailable in the individual participant data. Conclusion: For models that could be validated, predictive performance was generally poor across data sets. Although the International Prediction of Pregnancy Complications models show good predictive performance on average, and in the singleton nulliparous population, heterogeneity in calibration performance is likely across settings. Future work: Recalibration of model parameters within populations may improve calibration performance. Additional strong predictors need to be identified to improve model performance and consistency. Validation, including examination of calibration heterogeneity, is required for the models we could not validate. Study registration: This study is registered as PROSPERO CRD42015029349. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 72. See the NIHR Journals Library website for further project information.

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200 of 221 shown

Cited by

Metadata

Authors
Allotey, J., Laivuori, H., Snell, K. I., Smuk, M., Hooper, R., Chan, C. L., Ahmed, A., Chappell, L. C., von Dadelszen, P., Dodds, J., Green, M., Kenny, L., Khalil, A., Khan, K. S., Mol, B. W., Myers, J., Poston, L., Thilaganathan, B., Staff, A. C., Smith, G. C., Ganzevoort, W., Odibo, A. O., Ramírez, J. A., Kingdom, J., Daskalakis, G., Farrar, D., Baschat, A. A., Seed, P. T., Prefumo, F., da Silva Costa, F., Groen, H., Audibert, F., Masse, J., Skråstad, R. B., Salvesen, K. Å., Haavaldsen, C., Nagata, C., Rumbold, A. R., Heinonen, S., Askie, L. M., Smits, L. J., Vinter, C. A., Magnus, P. M., Eero, K., Villa, P. M., Jenum, A. K., Andersen, L. B., Norman, J. E., Ohkuchi, A., Eskild, A., Bhattacharya, S., McAuliffe, F. M., Galindo, A., Herraiz, I., Carbillon, L., Klipstein-Grobusch, K., Yeo, S., Teede, H. J., Browne, J. L., Moons, K. G., Riley, R. D., & Thangaratinam, S.
Affiliations
  • Barts Research Centre for Women’s Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
  • Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
  • Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Keele, UK
  • Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
  • Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, UK
  • Department of Women & Children’s Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
  • Action on Pre-eclampsia (APEC), Evesham, UK
  • Vice Chancellor’s Office, Faculty of Health & Life Sciences, University of Liverpool, Liverpool, UK
  • Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust and Molecular and Clinical Sciences Research Institute, St George’s University of London, London, UK
  • Department of Obstetrics and Gynaecology, Monash University, Monash Medical Centre, Clayton, VIC, Australia
  • Maternal and Fetal Health Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
  • Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
  • Department of Obstetrics and Gynaecology, NIHR Biomedical Research Centre, University of Cambridge, Cambridge, UK
  • Department of Obstetrics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
  • University of South Florida, Tampa, FL, USA
  • Department of Obstetrics and Gynaecology, University Hospital de Cabueñes, Gijón, Spain
  • Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
  • Department of Obstetrics and Gynaecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
  • Bradford Institute for Health Research, Bradford Teaching Hospitals, Bradford, UK
  • Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
  • Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
  • Department of Gynaecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
  • Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
  • Department of Obstetrics and Gynaecology, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
  • Department of Molecular Biology, Medical Biochemistry and Pathology, Université Laval, Québec City, QC, Canada
  • Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
  • Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway
  • Department of Obstetrics and Gynacology, Akershus University Hospital, Lørenskog, Norway
  • Department of Education for Clinical Research, National Center for Child Health and Development, Tokyo, Japan
  • South Australian Health and Medical Research Institute, Adelaide, SA, Australia
  • Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
  • NHMRC Clinical Trials Centre, University of Sydney, NSW, Australia
  • Care and Public Health Research Institute, Maastricht University Medical Centre, Maastricht, the Netherlands
  • Department of Gynaecology and Obstetrics, Odense University Hospital, University of Southern Denmark, Odense, Denmark
  • Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
  • Finnish Institute for Health and Welfare, Helsinki, Finland
  • General Practice Research Unit (AFE), Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
  • Institute for Clinical Research, University of Southern Denmark, Odense, Denmark
  • MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
  • Department of Obstetrics and Gynecology, School of Medicine, Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
  • Obstetrics & Gynaecology, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
  • UCD Perinatal Research Centre, UCD School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
  • Fetal Medicine Unit, Maternal and Child Health and Development Research Network (SAMID), Department of Obstetrics and Gynaecology, Hospital Universitario Cruces, Instituto de Investigación Hospital, Barakaldo, Spain
  • Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Madrid, Spain
  • Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
  • Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
  • School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
  • Monash Partners Academic Health Sciences Centre, Monash University and Monash Health, Melbourne, VIC, Australia
ORCID
Venue
Health Technology Assessment
Publisher
National Institute for Health and Care Research
Published
2020-12
Volume
24
Issue
72
Pages
1-252
ISSN
  • 1366-5278
  • 2046-4924
DOI
10.3310/hta24720
Cited by
30
References
24
Language
en
Licence
www.nationalarchives.gov.uk/doc/non-commercial-government-licence/non-commercial-government-licence.htm (unspecified)
Funders
Health Technology Assessment programme (14/158/02)

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