Recurrence of hypertensive disorders ofpregnancy: an individual patient

data metaanalysis

Presented by : Dr. R. Bagus Prakoso

Moderator: Prof. Dr. H. A. Kurdi, SpOG (K)

Hypertensive disorders of pregnancy (HDP)

are a common health problem

the second most common cause of

maternal death worldwide

They complicate approximately 2-8%

of all pregnancies

related to intrauterine

growth restrictionA major psychologic

impact on the woman and her

family

counseling on recurrence of a hypertensive disease in a futurepregnancy is important

many studies have focused on the investigation of recurrence rates of HDP

difficult because of many potential sources of bias

The primary goal of this IPD metaanalysis study was to calculate the recurrence risk of HDP. Secondarily, we aimed to show the recurrence of Individual hypertensive syndromes.

MATERIALS AND METHODSSources

literature search in the electronic libraries PubMed (Medline)and Embase.

The search covered all records until August 2012.

The following terms were used: ‘‘preeclampsia”

All studies that described cohorts of women with a history of a hypertensive disorder that resulted in a delivery at any

gestational age were eligible

Two independent reviewers (M.F.vO. and J.L.) screened theidentified articles for eligibility based on title and abstract.

Discrepancies were resolved by a third reviewer (W.G.)

MATERIALS AND METHODS Data collection

@ eligible articles, contact information of author was obtained through Medline, Embase, or the Internet.

Approached the authors by email to inform them about the IPD metaanalysis project and to invite them to share their data

The quality of all studies that were included was evaluated with the Newcastle Ottawa Scale for cohort studies

MATERIALS AND METHODSDefinitions

HDP were defined as GH, preeclampsia,superimposed preeclampsia, or HELLPsyndrome

Chronic hypertension was not an exclusion criterion for the IPD but was in some individual studies

Preeclampsia was defined as hypertension

diastolic blood pressure 90 mm Hg or systolic blood pressure 140 mm Hg on 2 occasions that were 4-5 hours apart

with proteinuria(defined as a positive [0.3 g/L]

proteinuria dipstick test, a protein/ creatinine ratio of 30

mg/mmol in a random sample or an urine protein excretion of 300 mg for

24 hrs)after 20 weeks’ gestation

Mild or severe preeclampsiawas not separately defined,

MATERIALS AND METHODSDefinitions

Women with hypertension at >20 weeks’ gestation without proteinuria or a significant rise in blood pressure (if a woman had

known chronic hypertension).

the presence or a history of preconceptional hypertension or detection of hypertension in the first one-half of the pregnancy

De novo proteinuria or a sudden increase in proteinuria if already present, qualified women with chronic hypertension

hemolysis (elevated lactate dehydrogenase levels [600 U/L], elevated liver enzymes by levels of aspartate transaminase or

alanine transferase 70 U/L, and low platelets <100,000/mm)

GH

Chronic hypertension

superimposed preeclampsia

HELLP syndrome

MATERIALS AND METHODSStatistical analysis

performed 3 post hoc sensitivity analyses:

Statistical analysis was performed with SPSS software (version 20.0; SPSS Inc, Chicago, IL)

and R software (version 3.0.1; The R Foundation for Statistical Computing).

RESULTS Study selection

The combineddatabase

comprised a total of

99,415 women

RESULTS Study selection

RESULTS Subgroup analysis

compared recurrence among multiple and singleton

pregnancies.

516 were multiple 56

98.553 were singleton 20.408

presence of thrombophilia &LMW-heparin use &

recurrence

56 women used prophylactic LMW-heparin 26

141 women didnot use LMW-heparin 56

without thrombophilia &LMW-heparin use &

recurrence

52 women used prophylactic LMW-heparin

244 women did not useLMW-heparin

8

104

10.9%

20.7%

39.7%

46%

15.4%

42.6%

COMMENT Main findings

The recurrence rate of an HDP (any type) is 20.7%

HELLP syndrome or delivery of an SGA child increasesrecurrence of HDP

Decrease gestational age at delivery in the index pregnancy increases both the chance of having

recurrence and the chance to deliver prematurely again

The use of LMW heparin was not protective forrecurrence in our data, but the numbers

are too small to draw conclusions

Women who were normotensive before pregnancy and who experienced recurrence of a hypertensive disorder

had a 4 times increased risk of the development of chronic hypertension after pregnancy.

CONCLUSION

AMONG WOMEN THAT EXPERIENCE HYPERTENSION IN PREGNANCY, RECURRENCE RATE IN NEXT PREGNANCY IS

RELATIVE LOW

COURSE OF DISEASE IS MILDER FOR MOST WOMEN WITH RECURRENT DISEASE

Is the study in paper you’ve read using survei or registration data?

This paper using registration data of samples

Induction vs deduction how this paper explain these ?

This paper using deduction method to reach its conclusion

Variabel scale, explain this papers varables

They are nominal (eq: race, medical hystory), categorical (eq: parous, conception), and interval data (almost all variabel convert into interval data)

Type of Variabel: dependent vs independent, explain what are them in this paper

Dependent: reccurence of hypertensiveIndependent: baseline and demografic characteristic

Type of Data: primer, secunder, tersier, explain about this paper type of data

Using secunder data

Group vs Individual data, explain about this papers type of data

Using group data

Routine vs ad hoc data, explain about this papers type of data

Ad hoc data

Central, variation, position measurement variable, explain about this papers variables

They are using central (mean and median ) and variation measurement

Master table, distribution table, crosstab table. Explain about this papers table data

The table has been explained previously

Graph: hystogram, ogive, stem & leaf, box-plot, bar, line, scatter. Explain about this papers graph

This paper mainly using bar graphic

Explain about this papers Quality data conclusion

It has 95% confidence interval

Bias, explain about this papers bias Metaanalyse data was very subjective.The study used data from the eighties,which caused data to be lost.The data that were obtained from very different study designs, settings, and populations.

Explain about this Papers number of sample for estimation and hypotetical test

They purposively selecting all samples that meet the inclusion criteria from 22 studies

Explain about this paper randomization sampling technique: simple, systematic, stratification, cluster ?

There is no randomisation

Statistic technique used in this paper Binomial regression model for dichotomous outcomes and of a random intercept random/effects linear regression model for continuous outcomes.

Explain about this paper statistical analysis / practice fraud

No statistical analysis fraud founded

Explain wheter there are mistaken in conclude the statistical analysis result

No conclusion mistaken noted

How they presented biostatistic analysis riset or vital registration, naratively / written ?

They present writtenly

Did they used madia to present biostatistic analysis riset?

SPSS and R software

Thank you ….