Competing-risks model in screening for pre-eclampsia in twin pregnancy according to maternal factors and biomarkers at 11-13 weeks' gestation

Ultrasound Obstet Gynecol. 2017 Nov;50(5):589-595. doi: 10.1002/uog.17531. Epub 2017 Sep 25.


Objective: To develop a model for screening for pre-eclampsia (PE) in twin pregnancies based on maternal demographic characteristics and medical history and biomarkers at 11-13 weeks' gestation.

Methods: This was a screening study in twin pregnancies at 11-13 weeks' gestation. Bayes theorem was used to combine the a-priori risk from maternal factors with various combinations of uterine artery pulsatility index (UtA-PI), mean arterial pressure (MAP), serum pregnancy-associated plasma protein-A (PAPP-A) and placental growth factor (PlGF) multiples of the median (MoM) values. The performance of screening for PE requiring delivery at < 32, < 37 and < 42 weeks' gestation was estimated in 1100 twin pregnancies and 35 948 singleton pregnancies with complete data on UtA-PI, MAP, PlGF and PAPP-A.

Results: In twin pregnancies that developed PE, the values of MAP and UtA-PI were increased and the values of PlGF and PAPP-A were decreased. The distributions of log10 MoM values of biomarkers with gestational age at delivery were similar to those that were previously reported in singleton pregnancies and it was therefore assumed that the same model could be used for both singleton and twin pregnancies. The performance of screening for PE by maternal factors was improved by the addition of MAP, UtA-PI and PlGF; there was no further improvement with the addition of PAPP-A. In a mixed population of singleton and twin pregnancies, combined screening by maternal factors, MAP, UtA-PI and PlGF and risk cut-off of 1 in 75 for PE at < 37 weeks, the detection rate of PE at < 32, < 37 and < 42 weeks in singleton pregnancies was 91%, 77% and 57%, respectively, at a screen-positive rate (SPR) of 13%; the respective rates for twin pregnancies were 100%, 99% and 97%, at a SPR of 75%.

Conclusion: First-trimester combined screening for PE in singleton pregnancies can be adapted for screening in twins, leading to detection of nearly all affected cases but at a high SPR. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Keywords: Bayes theorem; first-trimester screening; mean arterial pressure; placental growth factor; pre-eclampsia; pregnancy-associated plasma protein-A; pyramid of pregnancy care; survival model; uterine artery Doppler.

Publication types

  • Evaluation Study

MeSH terms

  • Adult
  • Arterial Pressure / physiology
  • Bayes Theorem
  • Biomarkers / analysis
  • Female
  • Gestational Age
  • Humans
  • Placenta Growth Factor / blood
  • Pre-Eclampsia / diagnosis*
  • Pregnancy
  • Pregnancy Trimester, Second / physiology*
  • Pregnancy, Twin / physiology*
  • Pregnancy-Associated Plasma Protein-A / analysis
  • Prenatal Diagnosis / methods*
  • Prospective Studies
  • Pulsatile Flow / physiology
  • Risk Assessment / methods*
  • Risk Factors
  • Uterine Artery / physiopathology


  • Biomarkers
  • PGF protein, human
  • Placenta Growth Factor
  • Pregnancy-Associated Plasma Protein-A