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Background: We assessed whether adding the biomarkers Pregnancy Associated Plasma Protein-A (PAPP-A) and Placental Growth Factor (PlGF) to maternal clinical characteristics improved the prediction of a previously developed model for gestational hypertension in a cohort of Ghanaian pregnant women. Methods: This study was nested in a prospective cohort of 1010 pregnant women attending antenatal clinics in two public hospitals in Accra, Ghana. Pregnant women who were normotensive, at a gestational age at recruitment of between 8 and 13 weeks and provided a blood sample for biomarker analysis were eligible for inclusion. From serum, biomarkers PAPP-A and PlGF concentrations were measured by the AutoDELFIA immunoassay method and multiple of the median (MoM) values corrected for gestational age (PAPP-A and PlGF) and maternal weight (PAPP-A) were calculated. To obtain prediction models, these biomarkers were included with clinical predictors maternal weight, height, diastolic blood pressure, a previous history of gestational hypertension, history of hypertension in parents and parity in a logistic regression to obtain prediction models. The Area Under the Receiver Operating Characteristic Curve (AUC) was used to assess the predictive ability of the models. Results: Three hundred and seventy three women participated in this study. The area under the curve (AUC) of the model with only maternal clinical characteristics was 0.75 (0.64-0.86) and 0.89(0.73-1.00) for multiparous and primigravid women respectively. The AUCs after inclusion of both PAPP-A and PlGF were 0.82 (0.74-0.89) and 0.95 (0.87-1.00) for multiparous and primigravid women respectively. Conclusion: Adding the biomarkers PAPP-A and PlGF to maternal characteristics to a prediction model for gestational hypertension in a cohort of Ghanaian pregnant women improved predictive ability. Further research using larger sample sizes in similar settings to validate these findings is recommended.
This study was nested in a prospective cohort of 1010 adult pregnant women with a singleton pregnancy and without known pre-existent hypertension recruited between July 2012 and March 2014 at Ridge Regional Hospital and Maamobi General Hospital in Accra. Accra, the capital city of Ghana, is cosmopolitan with high, middle and low-income persons from different ethnic backgrounds living and working in the city [18]. Persons from all the social strata access health services, including antenatal and delivery care in these public hospitals. These hospitals were also chosen because they have a high attendance so the recruitment of pregnant women into the study could be completed in a shorter time. Eligibility criteria for this study were gestational age at enrollment of between between 8 and 13 weeks, based on ultrasound scan. This specific subset of women was selected based on evidence that prediction with these biomarkers is most appropriate at this gestational age [7–10, 19–21]. Women with gestational age at enrollment of less than 8 weeks or more than 13 weeks (n = 411), without PlGF MoM values (n = 95) or women without outcome data (n = 131) were excluded. We used the principle of 10 outcome events per variable for logistic and Cox regression analysis [22–25] to obtain a sample size adequate for our analysis. With an incidence of gestational hypertension of 10% in the Ghanaian population [26], and eight variables in the prediction model, a sample size of 393 women was considered adequate for the analysis. The women were included in the study after they had given written informed consent and were interviewed by trained research assistants using a structured questionnaire for socio-demographic characteristics and obstetric history. They were followed up at each antenatal clinic visit till they delivered. None of the women who developed gestational hypertension progressed to preeclampsia. Pregnancy outcomes were obtained at delivery and from the hospital maternity register.
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