DOI: 10.1097/01.aoa.0000337897.50686.91

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Issn Print: 0275-665X

Publication Date: 2008/12/01


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Accuracy of Mean Arterial Pressure and Blood Pressure Measurements in Predicting Preeclampsia: Systematic Review and Meta-analysis

J.S. Cnossen; K.C. Vollebregt; N. de Vrieze; G. ter Riet; B.W. Mol; A. Franx; K.S. Khan; J.A. vam der Post

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Excerpt

Being able to predict which parturients are at risk for preeclampsia is crucial for providing proper monitoring and preventive treatment to improve maternal and neonatal outcomes. Studies on the accuracy of blood pressure (BP) measurement as a predictive test, however, have shown conflicting results, and routine use of BP as a diagnostic test (or the only one) for hypertensive disorders is uncertain. The authors of this systematic review/meta-analysis investigated the accuracy of systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) measurements in predicting preeclampsia in parturients by pooling results from a wide variety of past studies.
Appropriate reports were found in Medline, Embase, the Cochrane Library, and Medion, from inception to February 2007, with no language restrictions; article references were reviewed and authors contacted for additional information. The studies chosen reported on any technique to measure BP in parturients in any healthcare setting and of any level of risk for preeclampsia, including test accuracy studies allowing generation of 2×2 tables. Two reviewers independently selected articles for methodologic quality based on the quality assessment of diagnostic accuracy studies (QUADAS) criteria and assessed application of preventive treatment. Summary receiver operating characteristic curves and likelihood ratios were generated by 2×2 tables for the various levels and their thresholds.
Thirty-four studies, screening 60,599 women (3341 preeclamptic women) were included; 28 were prospective and 6 retrospective; 28 cohorts, 3 randomized controlled trials, and 3 case-control studies resulted in 135 2×2 tables. Only 7 studies reported on preventive treatment and only one (a cohort study) reported on severe preeclampsia. In low-risk women, the areas under the summary receiver operating characteristic curves for BP measurement in the second trimester were 0.68 [95% confidence interval, 0.64-0.72] for SBP; 0.66 (0.59-0.72) for DBP; and 0.76 (0.70-0.82) for MAP. First trimester patterns were similar. Second trimester MAP of ≥90 mm Hg showed a positive likelihood ratio of 3.5 (95% confidence interval, 2.0-5.0) and a negative likelihood ratio of 0.46 (0.16-0.75) in women thought to be at high risk. A DBP ≥75 mm Hg was the best BP predictor for preeclampsia at 13 to 20 weeks' gestation in a group with other high-risk predictors: positive likelihood ratio 2.8 (1.8-3.6), negative likelihood ratio 0.39 (0.18-0.71). Analyses of other subgroups did not show improved predictive accuracy.
Although the studies were widely diverse in methodology, quality, and findings, MAP predicted preeclampsia fairly well, much better than did SBP, DBP, or an increase of either or both. These findings suggest that BP measurements at the first antenatal visit for healthy, normotensive women in the first and second trimesters do not help predict preeclampsia. The authors suggested that future research must differentiate between mild and severe disease, because of the higher risks of both maternal and fetal morbidity and mortality in the latter. Investigators also should concentrate on developing algorithms that combine biochemical and biophysical markers, including BP measurements, to help improve predictive accuracy.
Editors Note: The following is an abstract of an editorial comment on the paper abstracted above by Cnossen et al. (“Accuracy of Mean Arterial Pressure and Blood Pressure Measurements in Predicting Pre-Eclampsia: Systematic Review and Meta-Analysis.

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