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

Allotey J, Snell K, Smuk M, Hooper R, Chan CL, Ahmed A, Chappell LC, von Dadelszen P, Dodds J, Green M, Kenny L, Khalil A, Khan KS, Mol BW, Myers J, Poston L, Thilaganathan B, Staff AC, Smith GC, Ganzevoort W, Lavuori H, Odibo AO, Ramirez JA, Kingdom J, Daskalakis G, Farrar D, Baschat AA, Seed PT, Prefumo F, da Silva Costa F, Groen H, Audibert F, Masse J, Skrastad RB, Salvesen KA, Haavaldsen C, Nagata C, Rumbold AR, Heinonen S, Askie LM, Smits LJ, Vinter CA, Magnus PM, Eero K, Villa PM, Jenum AK, Andersen LB, Norman JE, Ohkuchi A, Eskild A, Bhattachrva S, McAuliffe FM, Galindo A, Herraiz I, Carbillon L, Klipstein-Grobusch K, Yeo S, Teede HJ, Brown JL, Moons KG, Riley RD, Thangaratinam S
Record ID 32018000948
Authors' objectives: Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk is needed to plan management. 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.
Authors' results and conclusions: 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. 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.
Authors' methods: This was an individual participant data meta-analysis of cohort studies. Source data from secondary and tertiary care. We identified predictors from systematic reviews, and prioritised for importance in an international survey. Early-onset (delivery at < 34 weeks’ gestation), late-onset (delivery at ≥ 34 weeks’ gestation) and any-onset pre-eclampsia. 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 I2 and τ2. 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. 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.
Authors' identified further research: 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.
Project Status: Completed
Year Published: 2020
URL for published report:
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: England, United Kingdom
MeSH Terms
  • Pre-Eclampsia
  • Pregnancy Complications
  • Risk Factors
  • Prenatal Diagnosis
  • Predictive Value of Tests
  • Models, Statistical
  • IPD
Organisation Name: NIHR Health Technology Assessment programme
Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
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