OS090. Performance of candidate clinical and biochemical markers in screening early in pregnancy to detect women at high risk to develop preeclampsia.

INTRODUCTION: The advent of early preventive measures, such as low-dose aspirin targeting women at high risk of preeclampsia (PE), emphasizes the need for better detection. Despite the emergence of promising biochemical markers linked to the pathophysiological processes, systematic reviews have shown that, until now, no single tests fulfill the criteria set by WHO for biomarkers to screen for a disease. However, recent literature reveals that by combining various clinical, biophysical and biochemical markers into multivariate algorithms, one can envisage to estimate the risk of PE with a performance that would reach clinical utility and cost-effectiveness, but this remains to be demonstrated in various environments and health care settings. OBJECTIVES: To investigate, in a prospective study, the clinical utility of candidate biomarkers and clinical data to detect, early in pregnancy, women at risk to develop PE and to propose a multivariate prediction algorithm combining clinical parameters to biochemical markers. METHODS: 7929 pregnant women prospectively recruited at the first prenatal visit, provided blood samples, clinical and sociodemographic information. 214 pregnant women developed hypertensive disorders of pregnancy (HDP) of which 88 had PE (1.2%), including 44 with severe PE (0.6%). A nested case-control study was performed including for each case of HDP two normal pregnancies matched for maternal age, gestational age at recruitment, ethnicity, parity, and smoking status. Based on the literature we selected the most promising markers in a multivariate logistic regression model: mean arterial pressure (MAP), BMI, placental growth factor (PlGF), soluble Flt-1, inhibin A and PAPP-A. Biomarker results measured between 10-18 weeks gestation were expressed as multiples of the median. Medians were determined for each gestational week. RESULTS: When combined with MAP at the time of blood sampling and BMI at the beginning of pregnancy, the four biochemical markers discriminate normal pregnancies from those with HDP. At a 5% false positive rate, 37% of the affected pregnancies would have been detected. However, considering the prevalence of HDP in our population, the positive predictive value would have been only 15%. If all the predicted positive women would have been proposed a preventive intervention, only one out 6.7 women could have potentially benefited. In the case of severe PE, performance was not improved, sensitivity was the same, but the positive predictive value decreased to 3% (lower prevalence of severe PE). CONCLUSION: In our low-risk Caucasian population, neither individual candidate markers nor multivariate risk algorithm using an a priori combination of selected markers reached a performance justifying implementation. This also emphasizes the necessity to take into consideration characteristics of the population and environment influencing prevalence before promoting wide implementation of such screening strategies. In a perspective of personalized medicine, it appears more than ever mandatory to tailor recommendations for HDP screening according not only to individual but also to population characteristics.

PP054. Predicting preeclampsia at late mid-term pregnancy before occurrence of clinical symptoms: Clinical utility of biomarkers and clinical parameters in a low-risk population.

INTRODUCTION: Despite research efforts and healthcare improvement, preeclampsia (PE) continues to be a leading cause of maternal and fetal morbidity and mortality. Early identification of women at risk of developing PE is the most promising approach to implement preventive measures such as low-dose aspirin to reduce negative outcomes. However, it is still relevant to evaluate pregnant women to detect PE before the occurrence of clinical symptoms and/or to have better tools to assist in its differential diagnosis. Recently, measurements of biomarkers such as soluble fms-like tyrosine kinase-1 (SFLT-1) and placental growth factor (PlGF) have been proposed and some manufacturers are already marketing reagents for this purpose. OBJECTIVES: To examine in a prospective study the performance of selected clinical and biochemical markers for identifying late mid-term pregnancy women at risk of developing PE within a few weeks. METHODS: Seven thousand nine hundred and twenty nine pregnant women prospectively recruited at the first routine prenatal visit, provided blood samples, clinical and sociodemographic information. Two hundred and fourteen pregnant women developed hypertensive disorders of pregnancy (HDP) of which 88 had PE (1.2%), including 44 who presented with severe PE (0.6%). We performed a nested case-control study from the whole cohort including for each case of HDP two normal pregnancies after matching for maternal age, gestational age at recruitment, ethnicity, parity, and smoking status. Based on the literature, we selected the most promising clinical and biochemical markers to be included in a multivariate logistic regression model: mean arterial pressure and body mass index (BMI), PlGF, SFLT-1, inhibin A, and PAPP-A. All markers were measured between 20 and 32 weeks of gestation except for BMI (early pregnancy). All biological marker results were transformed in multiples of median. Medians were established for each gestational week. Multivariate logistic regression analyses were performed to develop prediction algorithm. RESULTS: The resulting regression model discriminated the affected from normal pregnancies as indicated by an area under the receiver operating characteristics (ROC) curve of 0.8. But at a 5% false positive rate, only 28% of the women who have developed HDP would have been detected. Even when the statistical analyses were limited to severe PE, the performance was poor: sensitivity 30%, positive predictive value 2.7%. CONCLUSION: In our low-risk Caucasian population, neither individual candidate markers nor multivariate risk algorithm using an a priori combination of selected clinical and biochemical markers reached a performance justifying implementation as a screening procedure. These results emphasize the necessity to take into consideration the environment, population and health care settings influencing prevalence and characteristics of HDP before promoting wide implementation of such screening strategies. It is imperative to tailor future recommendations for HDP screening not only according to the individual but also to the population characteristics if clinical utility has to be reached.

A photoacoustic study of water infiltrated leaves.

Photoacoustic measurements of photosynthetic energy storage were conducted on water infiltrated pea and sugar maple leaves. The samples were vacuum infiltrated with pure water or with a suitable buffer. The use of such methodology permitted an accurate determination of the energy storage parameter at low modulation frequencies, where in non-infiltrated leaves oxygen evolution dominates the photoacoustic signal and does not allow energy storage measurements. Differences between infiltration media were not essential, however the use of pure water as infiltration medium sometimes caused instability of the measured energy storage, particularly at longer experimental time. Values of energy storage in individual samples ranged mostly between 0.2 to 0.35. Measured as a function of the modulation frequency, energy storage was found to be constant from about 10 to 200 Hz for pea leaves. In sugar maple leaves, the energy storage slightly increased between 100 and 500 Hz. Obtaining an accurate value for energy storage also allowed an accurate estimation of the O2 evolution contribution to the photoacoustic signal of an unfiltrated leaf. In a maple leaf its frequency dependence showed only the effect of diffusion in the entire frequency range (10-500 Hz). Energy storage transients were observed after long periods (ca. 1/4-2 hrs) of dark adaptation upon the transition to light. In this case the initial energy storage was roughly about 1/2 that of the steady state value indicating strong PS I activity, while PS II was transiently incompetent. Energy-storage increased during illumination in a way to correspond to photosynthetic induction events as previously measured by fluorescence and O2 evolution. Transients in energy storage were also found following high light to low light transitions (i.e., switch off of the saturating background light), that paralleled similar transients in oxygen evolution, showing initial transient inactivation followed by progressive reactivation of PS II.

Photoacoustic Study of Changes in the Energy Storage of Photosystems I and II during State 1-State 2 Transitions.

Using photoacoustic spectroscopy, state 1-state 2 transitions were demonstrated in vivo in intact sugar maple leaves (Acer saccharum Marsh.) by following the changes in energy storage of photosystems (PS) I and II. Energy storage measured with 650 nm modulated light (light 2) in the presence of background white light indicated the total energy stored by both photosystems (ES(t)), and in the presence of background far-red light showed the energy stored by PSI (ES(psi)). The difference between ES(t) and ES(psi) gave the energy stored by PSII (ES(psii)). While ES(t) remained nearly constant during state transitions, both ES(psi) and ES(psii) changed considerably. The ratio of ES(psii) to ES(psi), an indicator of the energy distribution between the two photosystems, decreased or increased during transition to state 2 or state 1, respectively. State transitions were completed in about 20 min and were fully reversible. During transition from state 1 to state 2, the fraction of excitation energy gained by PSI was nearly equal to that lost by PSII. This fraction of excitation energy transferred from PSII to PSI accounted for about 5% of the absorbed light (fluorescence is not considered), 19% of ES(t), 34% of ES(psii), and 43% of ES(psi) in state 2. NaF treatment inhibited the transition to state 1. Data in the present study confirm the concept of changes in absorption cross-section of photosystems during state transitions.

Photosynthetic energy storage of Photosystems I and II in the spectral range of photosynthetically active radiation in intact sugar maple leaves.

The relative activity of Photosystems (PS) I and II in the spectral range between 400 and 720 nm was studied by measuring photosynthetic energy storage (ES) of an intact sugar maple leaf using photoacoustic spectroscopy. ES, determined with a modulated (80 Hz) monochromatic light beam in the presence of saturating intensity of background non-modulated white light, indicated the total energy stored by both photosystems (EST). Using background far-red light, ES of PS I (ESPS I) was quantified. ESPS II was derived from EST-ESPS I. EST dependence on intensity and wavelength of modulated light was studied at 470, 560, 640 and 680 nm. EST was maximum in red light and minimum in blue light. It decreased with an increase in modulated light intensity. The ratio ESPS II/ESPS I, measured at 640 nm, remained nearly constant with an increase in modulated light intensity. The relative quantum yield of EST spectrum showed two peaks around 610 and 660 nm, and declined sharply after 680 nm, revealing a clear red drop. ESPS I spectrum presented peaks around 610 and 670 nm, and a minimum between 440 and 470 nm. ESPS I was observed beyond 700 nm up to 720 nm, indicating the energy stored by cyclic electron transport. ESPS II spectrum showed broad peaks, around 460, 490, 600 and 660 nm, and a shoulder between 530 and 560 nm. ESPS II was always higher than ESPS I between 400 and 690 nm and reached zero around 700 nm.