Biomarkers for the prognosis of premature eclampsia

Abstract

The present invention relates to a method for the prognosis, prediction, risk assessment and / or risk stratification of pre-eclampsia in a pregnant subject, comprising determining a level of soluble fms-like tyrosine kinase-1 (sFlt-1) or a fragment thereof in a sample isolated from said pregnant subject.The present invention further relates to a method for the prognosis, prediction, risk assessment and / or risk stratification of early onset pre-eclampsia in a pregnant subject, comprising determining a level of (sFlt-1) or a fragment thereof in a sample isolated from said pregnant subject, wherein the sample is isolated from the subject before the end of the 12th week of gestation, and wherein the level of sFlt-1 or a fragment thereof is indicative of the likelihood of early onset pre-eclampsia occurring before the end of the 33rd week of gestation.The present invention further relates to a combined measurement of sFlt-1 and PlGF, optionally in combination with consideration of one or more further factors selected from maternal age, body mass index, uterine artery Doppler measurement and / or mean arterial pressure (MAP). The present invention further relates to a kit for carrying out the method of the present invention, comprising detection reagents for determining the level of sFlt-1 or a fragment thereof in a sample from a subject, and optionally for determining the level of at least one additional biomarker described herein.

Description

Technical Field

[0001] The present invention relates to the field of clinical and molecular diagnosis and prognosis diagnosis of medical conditions, particularly preeclampsia (PE).

[0002] Thus, the present invention is a method for prognosis, prediction, risk assessment and / or risk stratification of preeclampsia in a pregnancy subject, comprising determining the level of sFlt-1 or a fragment thereof in a sample isolated from the pregnancy subject, wherein the level of the sFlt-1 or the fragment thereof indicates the likelihood of preeclampsia.

[0003] The present invention is further a method for prognosis, prediction, risk assessment and / or risk stratification of early onset preeclampsia (EO-PE) in a pregnancy subject, comprising determining the level of soluble fms-like tyrosine kinase-1 (sFlt-1) or a fragment thereof in a sample isolated from the pregnancy subject, wherein the sample is isolated from the subject before the end of the 12th week of gestation, and the level of the sFlt-1 or the fragment thereof indicates the likelihood of early onset preeclampsia occurring before the end of the 33rd week of gestation.

[0004] The present invention is further a method for prognosis, prediction, risk assessment and / or risk stratification of early onset preeclampsia in a pregnancy subject, comprising determining the level of soluble fms-like tyrosine kinase-1 (sFlt-1) or a fragment thereof and the level of placental growth factor (PlGF) or a fragment thereof in a sample isolated from the pregnancy subject. The present invention is further related to the measurement of sFlt-1 and PlGF in combination with the consideration of one or more additional factors selected from maternal age, body mass index, uterine artery Doppler measurement and / or mean arterial pressure (MAP).

[0005] The present invention further relates to a kit for carrying out the method of the present invention, comprising a detection reagent for determining the level of sFlt-1 or fragments thereof in a sample from a subject, and optionally for determining the level of at least one additional biomarker described herein, such as PlGF. [Background technology]

[0006] Pre-eclampsia (PE) is a pregnancy-specific hypertensive disorder and a leading cause of maternal and perinatal morbidity and mortality worldwide. The World Health Organization (WHO) estimates that 16% of global maternal mortality (approximately 63,000 maternal deaths per year) is due to PE alone. Infants are also at risk. Pre-eclampsia exacerbates approximately 2–8 percent of all pregnancies and is a leading cause of maternal and fetal death worldwide (Duley 2009, Semin Perinatal:33:130-37). Pre-eclampsia is generally defined as pregnancy-related or induced hypertension and proteinuria that develops after 20 weeks of gestation. Premature eclampsia (EO-PE) is a low-incidence subgroup of pre-eclampsia cases, occurring in 0.2–0.4% of all pregnancies, and is associated with various adverse perinatal outcomes, including intrauterine fetal death (IUFD) and high perinatal mortality.

[0007] The risk of maternal mortality is far higher in resource-limited settings. The most frequently recognized factor contributing to major maternal and fetal morbidity is the failure to recognize pre-eclampsia in a timely manner. As a result, pregnant women may not receive effective monitoring or treatment until long after complications associated with the disorder, including elevated blood pressure and proteinuria, have developed. Furthermore, pregnant women with little to no risk of developing such disorders must undergo unnecessary testing for symptoms throughout their pregnancy, as there are no effective means for caregivers to rule them out of risk in the early stages of pregnancy.

[0008] International Publication 2008 / 103202(A2) discloses a method for diagnosing pregnancy-related hyperglycemia by measuring COMT, HIF-1α, EPO, LDH-A, ET-I, transferrin, transferrin receptor, and Flk-I, free VEGF, total VEGF, sFlt-1, and PlGF. Altered expression of these polypeptides compared to reference levels is an indicator of pregnancy-related hyperglycemia.

[0009] International Publication No. 2006 / 069373(A2) discloses a method for diagnosing whether a pregnant woman has or is at risk of developing hyperuricemia. The levels of sFlt-1 and placental growth factor (PlGF) are measured in a urine sample. The ratio of sFlt-1 expression to PlGF expression is used as an indicator of whether a woman is at risk of developing hyperuricemia.

[0010] International Publication 2004 / 008946(A2) discloses a method for treating or preventing pre-eclampsia or eclampsia in a subject, comprising the step of administering a compound capable of binding to soluble fms-like tyrosine kinase-1 (sFlt-1). It was further disclosed that higher sFlt-1 concentrations in patients prior to the onset of pre-eclampsia are due to an acute elevation of sFlt-1 within 5 weeks prior to the onset of the clinical disease.

[0011] To date, the most invasive treatment for pre-eclampsia is termination of pregnancy by either premature vaginal delivery or cesarean section. As mentioned above, in cases of pre-eclampsia before 34 weeks of gestation, maternal risks and fetal survival rates are significantly impaired. Therefore, attempts should be made to delay delivery and thereby improve neonatal survival. Tsakiridis et al. (Volume 76, Number 10, Obstetrical and Gynecological Survey) highlighted the content of pregnancy-related guidelines that describe early administration of low-dose aspirin in high-risk patients, ideally during the first trimester or at 36-37 weeks of gestation.

[0012] Improving the prognosis within the first stage of pre-eclampsia in women who are clinically asymptomatic or who have or are suspected of having pre-eclampsia is clinically very important.

[0013] In the most severe forms, such as premature preeclampsia (PE), treatment should be initiated as early as possible, ideally as early as week 11 of pregnancy, although early treatment may be started later, such as between weeks 12 and 15. Currently, approximately 60–66% of early PE and about 70% of premature PE are detected by the FMF algorithm. The Fetal Medicine Foundation (FMF) screening algorithm includes consideration of multiple maternal characteristics and medical history, including factors such as blood pressure, pregnancy-related plasma protein A and placental growth factor, crown-rump length, and uterine artery pulsation index. However, the FMF algorithm is complex and relies on uterine artery Doppler measurement, a technique not generally available to all pregnant subjects. There is an urgent need in this field for improved and simplified methods to determine the risk of preeclampsia, particularly premature preeclampsia, in the early stages of pregnancy. [Overview of the project]

[0014] In light of the prior art, the underlying technical problem of the present invention is to provide an improved or alternative means for prognosis, prediction, risk assessment, and / or risk stratification of pre-eclampsia in pregnant subjects. A further object of the present invention is to provide a means for early prognosis or risk assessment of pre-eclampsia. A further object of the present invention is to provide a prognostic approach for risk assessment of pre-eclampsia in the first trimester of pregnancy. A further object of the present invention relates to providing a means for improving and / or simplifying screening or prognosis of premature pre-eclampsia in the early stages of pregnancy, with increased sensitivity and preferably without requiring uterine artery Doppler measurement.

[0015] This problem is solved by the features of the independent claim. Preferred embodiments of the present invention are provided by the dependent claims.

[0016] Therefore, the present invention relates to a method for prognosis, prediction, risk assessment, and / or risk stratification of premature eclampsia in pregnant subjects, a. This includes determining the level of soluble fms-like tyrosine kinase-1 (sFlt-1) or its fragments in a sample isolated from the pregnant subject, b. The sample was isolated from the subject before the end of the 12th week of gestation (before 90-day GA), c. Methods indicating that the level of sFlt-1 or its fragments may indicate the possibility of pre-eclampsia occurring before the end of the 33rd week of gestation.

[0017] Therefore, the method described herein enables assessment of EO-PE risk in the early stages of pregnancy and thus provides clinicians with the possibility of initiating appropriate prophylactic treatment in the very early stages of pregnancy. In the most severe forms of PE, such as EO-PE, it is recommended to start treatment as early as possible, preferably as early as week 11 of pregnancy. Up until the present invention, molecular analysis has been available for PE prognosis, but the prognosis of the early stages of EO-PE has relied primarily on the FMF algorithm using uterine artery Doppler measurement. Therefore, the present invention enables a simple and reliable molecular diagnostic and / or prognostic approach aimed at identifying subjects at risk of EO-PE in the very early gestational age (GA).

[0018] Notably, sFlt-1 measurement, when determined from multiple samples obtained throughout the first trimester, does not provide a statistically relevant correlation with EO-PE (Figure 2, below). Even more noteworthy is that sFlt-1 measurement, when determined from multiple samples obtained 12 6 / 7 weeks after GA, also does not provide a statistically relevant correlation with EO-PE (Figures 3 and 4, below). Surprisingly, sFlt-1 measurement within 12 weeks of gestation or within 90 days shows a significant correlation with EO-PE, and in particular, an inverse correlation with EO-PE (Figures 5 and 6). Therefore, determining sFlt-1 within 90 days of GA enables a reliable prognosis of EO-PE at an early stage.

[0019] Various aspects of the present invention are unified by the common finding that levels of sFlt-1 or its fragments in samples derived from pregnant subjects of GA before the end of the 12th week, for example, 90 days before GA, indicate the possibility of premature eclampsia, and are based on, and / or associated therewith.

[0020] This invention provides an efficient and reliable test for healthcare professionals, such as physicians, nurses, and emergency room staff, to rapidly and accurately assess the likelihood of a pregnant subject developing PE. Typically, pregnant women with little to no risk of developing such a disorder must undergo unnecessary testing for symptoms throughout their pregnancy, as there is no effective means for caregivers to rule them out of risk in the early stages of pregnancy.

[0021] High levels of placental soluble fms-like tyrosine kinase (sFlt-1) are strongly associated with premature eruptions (PE) during the second and third trimesters of pregnancy (weeks 14-27 of gestation) and the third trimester (week 28 of gestation to delivery). Surprisingly, according to this invention, levels of sFlt-1 or its fragments during the first 90 days of pregnancy are also associated with early-onset PE, and low sFlt-1 levels indicate EO-PE.

[0022] Based on this remarkable discovery, the present invention provides means for identifying pregnant women who are at increased or high risk of developing EO-PE, and also means for identifying patients who are less likely to develop such complications, or whose development can be substantially ruled out, by determining the level of sFlt-1 or its fragments in samples isolated from patients.

[0023] A further advantage resulting from this amazing discovery is that, in addition to the conventional combination of biomarkers, clinical parameters, and imaging procedures for the prognosis diagnosis of PE, the prognostic marker sFlt-1 can be used in any medical setting regardless of whether a device for measuring the uterine artery pulsatility index (UAPI) is available. For this purpose, a special ultrasound examination device and experts for operating the device and performing the measurement are typically required. Therefore, a simple and minimally invasive test becomes possible.

[0024] What is even more noteworthy is the Aspirin for Evidence-Based Preeclampsia Prevention (ASPRE) trial, a multi-center trial that included women identified as having a high risk of early-onset PE according to the FMF algorithm randomized to receive aspirin or placebo from 11 to 14 weeks of gestation until 37 weeks of gestation. It showed a 62% reduction in early-onset PE with daily low-dose aspirin compared to the placebo group (relative risk, 0.38; 95% confidence interval [CI], 0.20 - 0.74).

[0025] If it is possible to accurately predict that a woman has a high risk of developing EO-PE during the first 12 weeks of pregnancy, this efficient treatment can be applied to pregnant women in the early stage of pregnancy. This brings another advantage based on the amazing discovery that a high risk of developing EO-PE can be predicted in the first trimester of pregnancy. As a result, for subjects predicted to have a high risk of developing PE, mild treatment, medication, or even frequent monitoring instead of any major measures (e.g., early termination of pregnancy after developing PE in the later stage of pregnancy), such as bed rest, can be carried out.

[0026] In one embodiment, the method further comprises a. determining the level of placental growth factor (PlGF) or a fragment thereof in a sample isolated from a subject, The combination of the level of b.sFlt-1 or a fragment thereof and the level of PlGF or a fragment thereof indicates the likelihood of early-onset preeclampsia before the end of the 33rd week of gestation.

[0027] As shown in more detail below, the combined use of sFlt-1 and PlGF provides a statistically improved prognosis for EO-PE when the sample is obtained in the early stages of pregnancy, for example, before the end of the 12th week of gestation (before 90 days GA). Notably, PlGF is typically effective in prognosticating EO-PE when measured after 90 days GA, while sFlt-1 does not appear to allow for a reliable prognostic statement from a single measurement after 90 days GA (Figure 7). Surprisingly, both sFlt-1 and PlGF enable EO-PE prognosis when measured before the end of 12 weeks (within 90 days) GA. However, sFlt-1 appears to provide greater sensitivity with an equivalent specificity value, preferably a value greater than 0.6 (Figure 8). Also surprisingly, the combined analysis of sFlt-1 and PlGF shows an unexpected multiplicative enhancement in EO-PE prognosis when measured before 90 days GA (Figure 9).

[0028] In an embodiment of the method, the subject is at 9 to 11 weeks of gestation.

[0029] In an embodiment of the method, the subject is at 11 weeks of gestation.

[0030] In an embodiment of the method, the subject has a gestational age (GA) of 50 to 90 days, preferably 60 to 90 days, or 70 to 90 days, such as 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, or 90 days GA.

[0031] As described above, these early time points for sampling and testing enable early treatment initiation, which can be important in effectively addressing and / or preventing the occurrence of severe PE.

[0032] In this embodiment, the method is a. Further including determining or providing the maternal age, body mass index and / or uterine artery Doppler measurement values ​​of the subject, b. Preferably, a combination of levels of sFlt-1 or its fragments, combined with levels of PlGF or its fragments, and the maternal age, body mass index, and / or uterine artery Doppler measurements of the subject, indicates pre-eclampsia occurring before the end of the 33rd week of gestation.

[0033] In this embodiment, the method is a. Further includes determining or providing the mean arterial pressure (MAP) level of the subject, b. Preferably, a combination of the level of sFlt-1 or a fragment thereof, combined with the level of the target MAP, indicates pre-eclampsia that occurs before the end of the 33rd week of gestation.

[0034] As shown in Figure 10 below, the combination of sFlt-1 and PlGF measurements, when combined with additional uterine artery Doppler measurements, demonstrates further improvement in diagnostic capabilities.

[0035] In this embodiment, the method is a. Determining the level of sFlt-1 or its fragments in the sample isolated from the subject, and determining the level of PlGF or its fragments, b. Determining or providing the maternal age, body mass index (BMI), and uterine artery Doppler measurement values, and optionally, mean arterial pressure (MAP), c. The combination of the level of sFlt-1 or its fragments, the level of PlGF or its fragments, and the maternal age, body mass index (BMI), and uterine artery Doppler measurement, and optionally, mean arterial pressure (MAP), indicates the likelihood of pre-eclampsia occurring before the end of 33 weeks of gestation.

[0036] In this embodiment, the method is a. Determining the level of sFlt-1 or its fragments in the sample isolated from the subject, and determining the level of PIGF or its fragments, b. Determining or providing the maternal age, body mass index (BMI), and mean arterial pressure (MAP), and optionally, uterine artery Doppler measurements, c. The combination of the level of sFlt-1 or its fragments, the level of PlGF or its fragments, the maternal age, body mass index (BMI), and mean arterial pressure (MAP), and optionally, uterine artery Doppler measurements, indicates the likelihood of pre-eclampsia occurring before the end of 33 weeks of gestation.

[0037] In embodiments of the present invention, the level of sFlt-1 or its fragments determined in a sample is compared to a reference level, preferably the population mean and / or median for a healthy population, and a level of sFlt-1 or its fragments below the reference level indicates a risk of pre-eclampsia, e.g., high risk.

[0038] In the embodiment, the reference level is determined from a population of healthy pregnancies from the same GA, or pregnancies that do not develop EO-PE.

[0039] In embodiments of the present invention, the level of PlGF or its fragments determined in a sample is compared to a reference level, preferably the population mean and / or median for a healthy population, and a level of PlGF or its fragments above the reference level indicates a risk of pre-eclampsia, e.g., high risk.

[0040] In embodiments of the present invention, a combination of the level of sFlt-1 or its fragments, preferably the level of said sFlt-1 or its fragments, the level of said PlGF or its fragments, and the maternal age, body mass index (BMI), uterine artery Doppler measurement, and optionally mean arterial pressure (MAP) indicates the early onset of pre-eclampsia occurring from the beginning of 20 weeks of gestation and the end of 33 weeks of gestation.

[0041] Further embodiments and aspects of the present invention relate to methods used herein for indicators of intrauterine fetal death (IUFD).

[0042] Embodiments of the present invention relate to the prognosis, prediction, risk assessment, and / or risk stratification of IUFD. The prognosis of IUFD may be independent of or in combination with the prognostic diagnosis of EO-PE. In other words, EO-PE may occur in combination with IUFD, or IUFD may occur independently of EO-PE. The features of the methods and kits described herein with respect to the prognosis of EO-PE are equally applicable to the prognosis of IUFD, and vice versa.

[0043] As shown in more detail below, the combined use of sFlt-1 and PlGF resulted in a better prognosis for IUFD when samples were obtained between 90 and 100 days before GA (Figure 11), and showed a statistically improved prognosis for IUFD when samples were obtained 90 days before GA (Figure 12).

[0044] In embodiments of the present invention, a combination of the level of sFlt-1 or its fragments, preferably the level of said sFlt-1 or its fragments, the level of said PlGF or its fragments, and the maternal age, body mass index (BMI), and uterine artery Doppler measurement, and optionally, mean arterial pressure (MAP), further indicates the subsequent occurrence of intrauterine fetal death (IUFD).

[0045] In embodiments of the present invention, the sample is a body fluid sample, such as a blood sample, such as a venous blood sample, a capillary blood sample, a serum sample, a plasma sample, a vaginal fluid sample, a saliva sample, or an amniotic fluid sample, preferably a blood, serum, or plasma sample.

[0046] In embodiments of the present invention, the level of sFlt-1 or its fragments, and optionally, the level of PlGF or its fragments, maternal age, body mass index (BMI), uterine artery Doppler measurement, and / or mean arterial pressure (MAP), indicates that treatment of the subject is initiated or modified, for example, to reduce the risk of developing pre-eclampsia, delay the onset of pre-eclampsia, and / or reduce the severity of pre-eclampsia, and / or protect organ function such as the kidneys and / or liver, by balancing the angiogenesis / anti-angiogenesis process in placental development, lowering blood pressure, etc.

[0047] In embodiments of the present invention, the treatment is selected from the group consisting of one or more diuretics, beta-blockers, ACE inhibitors, angiotensin II receptor blockers, calcium channel blockers, alpha-blockers, methyldopa, central agonists, and vasodilators, VEGF, PLGF, statins, arginine vasopressin receptor antagonists, L-arginine, citrulline, arginase (nor-NOHA) inhibitors, iron chelators (deferoxamine), heparin, magnesium sulfate, diazepam, phenytoin, vitamin D, calcium, molecular selenium inhibitors, in vitro extraction (e.g., apheresis), lifestyle recommendations, outpatient monitoring, and increased frequency of maternal and fetal monitoring, preferably low-dose acetylsalicylic acid or metformin.

[0048] In embodiments of the present invention, the treatment includes the administration of acetylsalicylic acid.

[0049] In embodiments of the present invention, the treatment includes the administration of metformin.

[0050] Therefore, the present invention relates to a method for treating a pregnant woman to reduce the risk of premature eclampsia, a. - This includes determining the level of soluble fms-like tyrosine kinase-1 (sFlt-1) or its fragments in a sample isolated from the pregnant subject, - The sample was isolated from the subject before the end of the 12th week of gestation (before 90-day GA), - The level of sFlt-1 or its fragments indicates the likelihood of pre-eclampsia occurring before the end of 33 weeks of gestation, for prognosis, prediction, risk assessment, and / or risk stratification of pre-eclampsia in pregnant subjects. b. The method includes administering a treatment to reduce the risk of developing pre-eclampsia, delay the onset of the condition, and / or reduce the severity of pre-eclampsia.

[0051] In embodiments, the treatments performed relate to, or include, balancing the angiogenesis / anti-angiogenesis processes in placental development, lowering blood pressure, and / or protecting the function of organs such as the kidneys and / or liver.

[0052] In embodiments of the treatment method, the treatment is selected from the group consisting of one or more diuretics, β-blockers, ACE inhibitors, angiotensin II receptor blockers, calcium channel blockers, α-blockers, methyldopa, central agonists, and vasodilators, VEGF, PLGF, statins, arginine vasopressin receptor antagonists, L-arginine, citrulline, arginase (nor-NOHA) inhibitors, iron chelators (deferoxamine), heparin, magnesium sulfate, diazepam, phenytoin, vitamin D, calcium, molecular selenium inhibitors, in vitro extraction (e.g., apheresis), lifestyle recommendations, outpatient monitoring, and increased frequency of maternal and fetal monitoring, preferably low-dose acetylsalicylic acid or metformin.

[0053] In one embodiment of the treatment method, the treatment includes the administration of acetylsalicylic acid.

[0054] In one embodiment of the treatment method, the treatment includes the administration of metformin.

[0055] In the embodiments, levels of sFlt-1 or its fragments at least 6% lower than those of the reference sample indicate initiating or modifying the treatment in question to reduce the risk of developing PE, delay the onset of PE, or at least reduce the severity of PE, such as by balancing angiogenesis / anti-angiogenesis processes in placental development, lowering blood pressure, or protecting organ function from the kidneys or liver.

[0056] In the embodiments, levels of sFlt-1 or its fragments that are at least 8% lower than the reference sample, or 12%, 15%, or 20% lower than the reference sample, indicate initiating or modifying the treatment of the subject to reduce the risk of developing PE, delay the onset of PE, or at least reduce the severity of PE, such as by balancing the angiogenesis / anti-angiogenesis processes in placental development, lowering blood pressure, or protecting organ function from the kidneys or liver.

[0057] A gynecologist and / or physician may determine the appropriate treatment for the subject according to the current condition, whether or not risk factors are present. In embodiments, levels of sFlt-1 or its fragments that are at least 8% lower than the reference sample, or 12%, 15%, or 20% lower than the reference sample, indicate initiating or modifying the subject's treatment to reduce the risk of developing PE, delay the onset of PE, or at least reduce the severity of PE, such as by balancing angiogenic / anti-angiogenic processes in placental development, lowering blood pressure, or protecting organ function from the kidneys or liver.

[0058] A gynecologist and / or physician may determine the appropriate treatment for the subject according to the current condition, whether or not it is accompanied by risk factors.

[0059] In some embodiments, aspirin treatment may be initiated before 16 weeks of gestation, which has been associated with a significant reduction in premature preeclampsia (PE). The Evidence-Based Aspirin for Preeclampsia Prevention (ASPRE) trial, a multicenter study including women identified as being at high risk of premature PE, randomized to receive either aspirin or placebo from 11-14 weeks of gestation to 37 weeks of gestation according to an FMF algorithm, showed a 62% reduction in premature PE with daily low-dose aspirin compared to placebo (relative risk, 0.38; 95% confidence interval [CI], 0.20-0.74).

[0060] In embodiments of the present invention, the subject has one or more risk factors selected from the group consisting of hypothyroidism, hyperthyroidism, BMI greater than 24, primiparous pregnancy, history of pre-eclampsia, ethnicity with risk disorders, multiple pregnancy, migraine, lupus, blood coagulation disorders such as hypercoagulation, inflammatory diseases, cardiac predisposition, diabetes mellitus, chronic kidney disease, and chronic hypertension.

[0061] In embodiments of the present invention, the method further comprises determining the level of at least one additional biomarker or fragment thereof in a sample from the patient, the at least one additional biomarker being βhCG, copeptin, vasopressin, troponin, BNP, ANP, CRP, thrombocytocyte / leukocyte, IL6, IL11, MR-proADM, VEGF, PAPP-A, PIGF, endoglin, pro-Epil, PP-13, ADAM-12, vitamin D, inhibin-a, activin-a, pentraxin-3, p-selectin, free fetal hemoglobin, α-1-microglobulin, unconjugated estriol, α-fetoprotein, GDF15, neurophysin II, L NPEP, ESM1, HGF, Pikachurin, Hemopexin, pp13, uE3, CT-proET1, ADAM12, sTNFαR1, RBP4, ICAM, Cell-Free Fetal DNA, FSTL3, Bisfatin, AFP, MMP9, TIMP1, Flt1, PCT, SHGB, Creatinine, GBP1, IGFALS, Uterine Protein, PAI1 / PAI2, Catechol-o-methyltransferase (COMT), Heme Degradation Products (Bilirubin, Biliverdin, Carbon Monoxide, Ferritin), Arginine Degradation Products (Urea, Ornithine, Citrulline, Apolipoprotein H, Arginosuccinate, Ammonia), Uterine Artery Doppler Selected from the group consisting of artery Doppler (UtA-Pi), diastolic notch, MAP, blood pressure, smoking, leptin, genetic information, and arginine, the levels of at least one additional biomarker and the levels of sFlt-1 or a fragment thereof indicate pre-eclampsia prematurely before the end of 33 weeks of gestation.

[0062] In this embodiment, additional markers PAPP-A and / or PIGF are used in combination with sFlt-1.

[0063] In this embodiment, additional markers MAP, PAPP-A, and / or PlGF are used in combination with sFlt-1.

[0064] In this embodiment, additional markers MAP, PAPP-A, βhGC, and / or PlGF are used in combination with sFlt-1.

[0065] In embodiments of the present invention, the target is a heifer.

[0066] In embodiments of the present invention, the subjects had one or more previous pregnancies.

[0067] In embodiments of the present invention, the subject is a multiple pregnancy.

[0068] In embodiments of the present invention, the subject is suspected of being pregnant with a fetus that has a chromosomal abnormality.

[0069] Further aspects of the present invention relate to a kit for carrying out the method described herein.

[0070] In this embodiment, the kit is -A detection reagent for determining the level of sFlt-1 or its fragments in a sample from a target, and / or for determining the level of PIGF or its fragments, -Includes computer-readable media and / or computer software in the form of computer-executable code, configured to perform analyses useful for determining EO-PE risk.

[0071] In the embodiment, a computer-readable medium and / or computer software in the form of computer executable code is, i. The determined levels of i.sFlt-1 or its fragments and the determined levels of PlGF or its fragments are preferably compared to one or more reference levels corresponding to the population mean and / or median for a healthy population. ii. The system is configured to compare the subject's maternal age, body mass index, MAP, and / or uterine artery Doppler measurement with one or more reference levels, preferably corresponding to the population mean and / or median for a healthy population.

[0072] In embodiments of the present invention, the software in the kit, or the software configured to be connected to the kit, enables the comparison of determined molecular markers, such as those described herein, and provides a prognostic statement regarding EO-PE risk based on samples obtained within 90 days GA.

[0073] In embodiments of the present invention, the kit includes a physical disk or computer-readable medium having the software, or the kit provides a link or other code such as a QR code (registered trademark) suitable for inducing and / or providing a connection to a server over the Internet, and the appropriate software can be maintained and / or executed.

[0074] Further aspects and embodiments of the present invention: The present invention relates to a method for prognosis, prediction, risk assessment, and / or risk stratification of pre-eclampsia in pregnant subjects, a. This includes determining the level of sFlt-1 or its fragments in a sample isolated from the pregnant subject, b. The method by which the level of sFlt-1 or its fragments indicates the possibility of pre-eclampsia.

[0075] The present invention relates to a kit for carrying out the method of the present invention, comprising a detection reagent for determining the level of sFlt-1 or fragments thereof in a sample from a subject, and optionally for determining the level of at least one additional biomarker described herein, wherein the kit further comprises one or more reference levels, such as cutoff levels, corresponding to reference levels indicating a high or low risk of pre-eclampsia.

[0076] Therefore, the present invention further relates to a method for prognosis, prediction, risk assessment and / or risk stratification of pre-eclampsia in pregnant subjects, a. This includes determining the level of sFlt-1 or its fragments in a sample isolated from the pregnant subject, b. The level of sFlt-1 or its fragments indicates the possibility of pre-eclampsia, c. Methods by which the sample is isolated from the subject by the end of the 12th week of pregnancy.

[0077] In one embodiment, the target is the 9th to 11th week of pregnancy, preferably the 11th week.

[0078] Surprisingly, a significant difference in the predictive value (AUC) of sFlt-1 for early-onset PE was observed among women recruited at 11, 12, and 13 weeks of gestation. The AUC for predicting early-onset PE levels of sFlt-1 in samples from women recruited at 11 weeks of gestation reached 0.82. The AUC for predicting early-onset PE levels of sFlt-1 in samples from women recruited at 12 weeks of gestation reached 0.62. The AUC for predicting early-onset PE levels of sFlt-1 in samples from women recruited at 13 weeks of gestation reached 0.50. A similar trend, surprisingly, was observed for the prediction of mid-term PE.

[0079] The advantage of this remarkable discovery is that by determining the level of sFlt-1 or its fragments in early pregnancy, particularly at 11 weeks of gestation, the likelihood of developing PE can be accurately predicted.

[0080] In this embodiment, the mother's age is less than 18 years.

[0081] In this embodiment, the maternal age is 18 to 34 years.

[0082] In this embodiment, the mother's age is over 34.

[0083] Surprisingly, a difference in the predicted values ​​(AUC) of sFlt-1 was observed between maternal ages of 18-34 and over 34.

[0084] Pregnant women with a maternal age of 34 or older may have a greater chance of a reduced risk of premature birth, hypertension, concomitant pulmonary embolism (PE), severe PE, and chorioamnionitis.

[0085] Pregnancies with a maternal age of 40 or older may have an increased probability of mild PE, fetal distress, and low fetal growth.

[0086] It is highly advantageous for the indicated risk groups, including maternal ages under 18, 34 and over, and 40 and over, to be able to know the accurate prognosis of pre-eclampsia before or at the end of the 12th week of gestation.

[0087] In embodiments, the methods described herein include the following: a. The level of sFlt-1 or its fragments determined in the sample is compared to a reference level derived from a reference sample. b. Here, a level of sFlt-1 or its fragments below the reference level indicates a high risk of pre-eclampsia, or c. Levels of sFlt-1 or its fragments above the reference level indicate a low risk of pre-eclampsia.

[0088] In the embodiment, the reference level is derived from a reference sample isolated from a pregnant subject who does not have or suffers from any pregnancy-related hyperemesis gravidarum disorder such as PE or eclampsia.

[0089] In the embodiment, a level of sFlt-1 or its fragments that is at least 2–5% lower than that of the reference sample indicates a high risk of PE. In the embodiment, a level of sFlt-1 or its fragments that is less than 2% lower than that of the reference sample indicates a low risk of PE.

[0090] In the embodiment, a level of sFlt-1 or its fragments that is at least 5.8% lower than that of the reference sample indicates a high risk of PE. In the embodiment, a level of sFlt-1 or its fragments that is less than 5.8% lower than that of the reference sample indicates a low risk of PE.

[0091] In the embodiment, a level of sFlt-1 or its fragments at least 8% lower than that of the reference sample indicates a high risk of PE. In the embodiment, a level of sFlt-1 or its fragments less than 8% lower than that of the reference sample indicates a low risk of PE.

[0092] In the embodiment, a level of sFlt-1 or its fragments that is at least 12% lower than that of the reference sample indicates a high risk of PE. In the embodiment, a level of sFlt-1 or its fragments that is less than 12% lower than that of the reference sample indicates a low risk of PE.

[0093] In the embodiment, a level of sFlt-1 or its fragments that is at least 15% lower than that of the reference sample indicates a high risk of PE. In the embodiment, a level of sFlt-1 or its fragments that is less than 15% lower than that of the reference sample indicates a low risk of PE.

[0094] In the embodiment, a level of sFlt-1 or its fragments that is at least 20% lower than that of the reference sample indicates a high risk of PE. In the embodiment, a level of sFlt-1 or its fragments that is less than 20% lower than that of the reference sample indicates a low risk of PE.

[0095] In the embodiment, a level of sFlt-1 or its fragments that is at least 5.8% lower than that of the reference sample indicates a high risk of end-stage PE. In the embodiment, a level of sFlt-1 or its fragments that is less than 5.8% lower than that of the reference sample indicates a low risk of end-stage PE.

[0096] In the embodiment, a level of sFlt-1 or its fragments at least 8.8% lower than that of the reference sample indicates a high risk of end-stage PE. In the embodiment, a level of sFlt-1 or its fragments less than 8.8% lower than that of the reference sample indicates a low risk of end-stage PE.

[0097] In the embodiment, a level of sFlt-1 or its fragments that is at least 11% lower than that of the reference sample indicates a high risk of end-stage PE. In the embodiment, a level of sFlt-1 or its fragments that is less than 11% lower than that of the reference sample indicates a low risk of end-stage PE.

[0098] In the embodiment, a level of sFlt-1 or its fragments at least 14.7% lower than that of the reference sample indicates a high risk of early-onset PE. In the embodiment, a level of sFlt-1 or its fragments less than 14.7% lower than that of the reference sample indicates a low risk of early-onset PE.

[0099] In the embodiment, a level of sFlt-1 or its fragments at least 16.7% lower than that of the reference sample indicates a high risk of early-onset PE. In the embodiment, a level of sFlt-1 or its fragments less than 16.7% lower than that of the reference sample indicates a low risk of early-onset PE.

[0100] In the embodiment, a level of sFlt-1 or its fragments that is at least 20% lower than that of the reference sample indicates a high risk of early-onset PE. In the embodiment, a level of sFlt-1 or its fragments that is less than 20% lower than that of the reference sample indicates a low risk of early-onset PE.

[0101] In the embodiment, the level of sFlt-1 or its fragments indicates an early onset of PE occurring from the beginning of 20 weeks of gestation to the end of 33 weeks of gestation, or a mid-term onset of PE occurring from the beginning of 34 weeks of gestation to the end of 36 weeks of gestation.

[0102] In the embodiment, levels of sFlt-1 or its fragments in the sample that are at least 15%, preferably 20%, lower than the reference level indicate early onset of PE occurring between the beginning of 20 weeks of gestation and the end of 33 weeks of gestation.

[0103] In the embodiment, levels of sFlt-1 or its fragments in a sample less than 15% lower than the reference level indicate a low risk of early onset of PE.

[0104] In the embodiment, levels of sFlt-1 or its fragments in the sample that are at least 6%, preferably 12%, lower than the reference level indicate early onset of PE occurring from the beginning of 20 weeks of gestation to the end of 33 weeks of gestation, or mid-term onset of PE occurring from the beginning of 34 weeks of gestation to the end of 36 weeks of gestation.

[0105] In embodiments, a further risk parameter is the sex of the fetus. Surprisingly, a significant difference in the predicted value (AUC) of sFlt-1 levels, as well as a significant decrease in sFlt-1 levels compared to the reference level, can be observed in samples from subjects having at least a female fetus or at least a male fetus. In embodiments, the level of sFlt-1 in the subject samples is at least 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, or 25% lower compared to the reference level. Based on this surprising finding, subjects possessing such risk parameters can be predicted to be at risk of PE.

[0106] One aspect of the present invention is a kit for carrying out the method of the present invention, -A detection reagent for determining the level of sFlt-1 or its fragments in a sample from a subject, and optionally for determining the level of at least one additional biomarker described herein, preferably PAPP-A and / or PIGF, -The kit includes one or more reference levels, such as cutoff levels, that correspond to reference levels indicating a high or low risk of pre-eclampsia.

[0107] In one embodiment, the present invention is a kit for carrying out the method described herein, -A detection reagent for determining the level of sFlt-1 or its fragments in a sample from a subject, and optionally for determining the level of at least one additional biomarker described herein, preferably PAPP-A and / or PIGF, - A reference level, for example, one or more cutoff levels, Levels of sFlt-1 or its fragments in samples isolated from subjects up to 18 years of age showing risk of pre-eclampsia, The level of sFlt-1 or its fragments in samples isolated from subjects aged 18-34 years showing risk of pre-eclampsia, or Includes a reference level corresponding to the level of sFlt-1 or its fragments in samples isolated from subjects over 34 years of age who are at risk of pre-eclampsia, The kit relates to a system in which the reference level is stored in a computer-readable medium and / or used in the form of computer-executable code configured to compare the determined level of sFlt-1 or a fragment thereof, and optionally, the determined level of at least one additional biomarker, with the reference level.

[0108] In one embodiment, a kit for carrying out the method described herein is -A detection reagent for determining the level of sFlt-1 or its fragments in a sample from a subject, and optionally for determining the level of at least one additional biomarker described herein, preferably PAPP-A and / or PIGF, - A reference level, for example, one or more cutoff levels, The level of sFlt-1 or its fragments in samples isolated from subjects with blood type AB who are at risk of pre-eclampsia, or The level of sFlt-1 or its fragments in samples isolated from subjects with blood type Rh-negative blood who are at risk of pre-eclampsia, or The level of sFlt-1 or its fragments in samples isolated from subjects who are Rh-negative and have a biological father of an Rh-positive fetus at risk of pre-eclampsia, or Levels of sFlt-1 or its fragments in samples isolated from subjects pregnant with at least one female fetus at risk of pre-eclampsia, or Levels of sFlt-1 or its fragments in samples isolated from subjects pregnant with at least one male fetus at risk of pre-eclampsia, or The level of sFlt-1 or its fragments in samples isolated from nulliparous subjects at risk of pre-eclampsia, or The level of sFlt-1 or its fragments in samples isolated from subjects with one or more previous pregnancies at risk of pre-eclampsia, or the level of sFlt-1 or its fragments in samples isolated from subjects with multiple pregnancies at risk of pre-eclampsia, This includes a reference level corresponding to the level of sFlt-1 or its fragments in a sample isolated from a subject suspected of being pregnant with a fetus with a chromosomal abnormality that indicates a risk of pre-eclampsia, The reference level is stored in a computer-readable medium and / or used in the form of computer-executable code configured to compare the determined level of sFlt-1 or a fragment thereof, and optionally, the determined level of at least one additional biomarker, with the reference level.

[0109] In one embodiment, a kit for carrying out the method described herein is -A detection reagent for determining the level of sFlt-1 or its fragments in a sample from a subject, and optionally for determining the level of at least one additional biomarker described herein, preferably PAPP-A and / or PIGF, - A reference level, for example, one or more cutoff levels, The level of sFlt-1 or its fragments in isolated samples from the subjects indicates the risk of early onset of pre-eclampsia occurring between the beginning of 20 weeks of gestation and the end of 33 weeks of gestation. The level of sFlt-1 or its fragments in samples isolated from subjects at risk of mid-term pre-eclampsia occurring between the beginning of 34 weeks of gestation and the end of 36 weeks of gestation, or This includes a reference level corresponding to the level of sFlt-1 or its fragments in a sample isolated from a subject showing a low risk of developing pre-eclampsia, The reference level is stored in a computer-readable medium and / or used in the form of computer-executable code configured to compare the determined level of sFlt-1 or a fragment thereof, and optionally, the determined level of at least one additional biomarker, with the reference level.

[0110] The present invention relates to a method for identifying subjects at risk of preeclampsia (occurring before the end of the 33rd week of gestation) and for treating such subjects, (a) Diagnosis, prognosis, prediction, risk assessment and / or risk stratification of premature preeclampsia in pregnant subjects, - This includes determining the level of soluble fms-like tyrosine kinase-1 (sFlt-1) or its fragments in a sample isolated from the pregnant subject, - The sample was isolated from the subject before the end of the 12th week of gestation (before 90-day GA), - The level of sFlt-1 or its fragments indicates the possibility of pre-eclampsia occurring before the end of 33 weeks of gestation, for diagnosis, prognosis, prediction, risk assessment, and / or risk stratification. (b) The method further comprises administering to the subject a treatment for premature eclampsia or a treatment to reduce the risk of premature eclampsia.

[0111] The present invention relates to a method for detecting soluble fms-like tyrosine kinase-1 (sFlt-1) or a fragment thereof in a sample derived from a subject, The present invention includes providing a sample of interest, preferably a blood sample or a sample derived from a blood sample, having a complex comprising at least one binder for -sFlt-1 or a fragment thereof, and preferably providing a sample of interest, preferably a blood sample or a sample derived from a blood sample, having a complex comprising at least one binder for PlGF or a fragment thereof. -The method further relates to a sample having a threshold, for example, any threshold disclosed herein, preferably an sFlt-1 level below or above the population mean and / or population median of sFlt-1 levels from normal pregnancy at any given time in each patient population, preferably a PlGF level.

[0112] The present invention relates to a method for treating preeclampsia prematurely occurring before the end of the 33rd week of gestation and / or reducing the risk of preeclampsia prematurely, or for administering a treatment for preeclampsia prematurely, -Including administration for the treatment of premature eclampsia, -The subject further relates to a method for determining that a body fluid sample of a subject, preferably a blood sample or a sample derived from a blood sample, has a level of sFlt-1, preferably PlGF, below or above a threshold level from a normal pregnancy at any given time point in a patient population, for example, any threshold disclosed herein, preferably the population mean and / or population median.

[0113] Embodiments describing the method of the present invention may be used to describe the kit of the present invention, and vice versa. Features disclosed in some embodiments of the present method may also be used to characterize other embodiments of the present method or other methods of the present invention. The present invention is integrated by the novel and beneficial use of the prognostic marker sFlt-1 to indicate the risk of developing EO-PE in samples obtained by 12 weeks (90 days) GA. Accordingly, relevant features described herein in one embodiment may be used to describe any given embodiment of the present invention in a manner that is easy for those skilled in the art to understand. [Modes for carrying out the invention]

[0114] All cited patent and non-patent literature is incorporated herein by reference in its entirety.

[0115] The present invention relates to a method for prognosis, prediction, risk assessment, and / or risk stratification of pre-eclampsia in pregnant subjects, comprising: a) determining the level of sFlt-1 or its fragments in a sample isolated from the pregnant subject; and b) the level of sFlt-1 or its fragments indicating the possibility of pre-eclampsia.

[0116] As used herein, the term “subject” means a mammal (including, but not limited to, human or non-human mammals (e.g., cattle, horses, dogs, sheep, or cats)). This definition includes pregnant mammals, postpartum mammals, and non-pregnant mammals.

[0117] In this invention, the terms “risk assessment” and “risk stratification” relate to grouping subjects into different risk groups according to their further prognosis. Risk assessment also relates to stratification for the application of preventive and / or therapeutic measures. The term “therapy stratification” particularly relates to grouping or classifying patients into different groups, such as risk groups or therapy groups that receive certain different therapeutic measures depending on the patient’s classification.

[0118] As used herein, “prognosis” refers to the outcome or prediction of a particular risk for a person who develops PE. This may also include estimations of the likelihood of recovery or adverse outcomes for such person. Furthermore, the assessment of the severity of PE may be encompassed within the terms “prognosis,” “risk assessment,” or “risk stratification.”

[0119] As used herein, “preeclampsia” (PE) is used in its ordinary sense. PE can be defined according to well-established criteria, such as a blood pressure of at least 140 / 90 mmHg and at least 0.3 grams of protein excreted in the urine in a 24-hour urinary protein excretion period (or at least +1 on a dipstick test), measured twice, 4 to 6 hours apart.

[0120] Pre-eclampsia is considered a multisystem disorder characterized by hypertension, glomerular dysfunction, cerebral edema, hepatic edema, or coagulation abnormalities due to pregnancy or recent pregnancy, accompanied by proteinuria or edema, or both. Pre-eclampsia generally occurs after 20 weeks of gestation. Pre-eclampsia is generally defined as a combination of the following symptoms: (1) systolic blood pressure (BP) >140 mmHg and diastolic BP >90 mmHg after 20 weeks of gestation (generally measured twice at intervals of 4 to 168 hours), (2) newly developed proteinuria (1+ on dipstick during urinalysis, protein >300 mg in 24-hour urine collection, or a single random urine sample with a protein / creatinine ratio >0.3), and (3) resolution of hypertension and proteinuria by 12 weeks postpartum. Severe pre-eclampsia is generally defined as proteinuria characterized by (1) diastolic blood pressure > 110 mmHg (typically measured twice at intervals of 4 to 168 hours) or (2) measurement of 3.5 g or more of protein in a 24-hour urine collection or two random urine samples with at least 3+ protein measured by dipstick.

[0121] In pre-eclampsia, hypertension and proteinuria generally occur within 7 days of each other. In severe pre-eclampsia, severe hypertension, severe proteinuria, and HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) or eclampsia may occur simultaneously or as only one symptom at a time. Occasionally, severe pre-eclampsia can lead to the onset of seizures. This severe form of syndrome is called eclampsia. Eclampsia can also include dysfunction or damage to several organs or tissues, such as the liver (e.g., hepatocellular damage, periportal necrosis) and the central nervous system (e.g., cerebral edema and cerebral hemorrhage). The etiology of the seizures is thought to be secondary to the onset of cerebral edema and focal spasms of small blood vessels in the kidneys.

[0122] "Severe pre-eclampsia" or "high-severity pre-eclampsia" is also defined, according to established criteria, as blood pressure of at least 160 / 110 mmHg at least twice at 6-hour intervals, and more than 5 grams of protein in 24-hour urinary protein excretion, or persistent +3 proteinuria on a dipstick test.

[0123] Severe pre-eclampsia may include HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). Other elements of severe pre-eclampsia may include in-utero growth restriction (IUGR) below the 10th percentile in the US demographic, persistent neurological symptoms (headache, visual disturbances), epigastric pain, oliguria (less than 500 mL / 24 hours), serum creatinine >1.0 mg / dL, elevated liver enzymes (more than twice normal), and thrombocytopenia (<100,000 cells / [mu]L).

[0124] As used herein, “preterm birth” is defined as a birth occurring before the 37th week of gestation.

[0125] As used herein, “premature PE” is defined as PE delivered before the 37th week of gestation.

[0126] As used herein, “early onset of preeclampsia” means that the symptoms of preeclampsia occur between the beginning of the 20th week of gestation and the end of the 33rd week of gestation. In embodiments, early onset of preeclampsia refers to cases in which the baby is born before the 34th week of gestation.

[0127] As used herein, “mid-term onset of preeclampsia” means that the symptoms of preeclampsia occur between the beginning of the 34th week of gestation and the end of the 36th week of gestation.

[0128] As used herein, “prime onset of preeclampsia” means that the symptoms of preeclampsia begin at 37 weeks of gestation.

[0129] For example, “symptoms of pre-eclampsia” may include: (1) systolic blood pressure (BP) >140 mmHg and diastolic BP >90 mmHg at 20 weeks of gestation, (2) newly developed proteinuria (1+ on dipstick urinalysis, >300 mg of protein in 24-hour urine collection, or random urinary protein / creatinine ratio >0.3), and (3) resolution of hypertension and proteinuria by 12 weeks postpartum. Symptoms of pre-eclampsia may also include renal dysfunction and glomerular endotheliopathy or hypertrophy.

[0130] As used herein, “symptoms of eclampsia” means the onset of any of the following symptoms due to pregnancy or recent pregnancy, namely seizures, coma, thrombocytopenia, hepatic edema, pulmonary edema, and cerebral edema.

[0131] "At risk of developing" a pregnancy-related hyperkinesthetic disorder such as pre-eclampsia or eclampsia refers to a subject who does not currently have a pregnancy-related hyperkinesthetic disorder but is at a higher-than-average likelihood of developing one. Such subjects at risk include pregnant subjects with reduced serum sFlt-1 levels, but not limited to, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, or 25% compared to the reference level. In some embodiments, the patient may not exhibit other signs of a pregnancy-related hyperkinesthetic disorder such as pre-eclampsia.

[0132] As used herein, the term “indicating a pre-eclampsia risk” refers to a subject who does not currently have pre-eclampsia but has a greater-than-average likelihood of developing it. Such prognosis or risk assessment is based on a determined level of sFlt-1 or its fragments. The level of sFlt-1 or its fragments indicates the likelihood of developing pre-eclampsia. In one embodiment, the level of sFlt-1 or its fragments determined in a sample is compared to a reference level, where a level of sFlt-1 or its fragments below the reference level indicates a high risk of pre-eclampsia, or a level of sFlt-1 or its fragments above the reference level indicates a low risk of pre-eclampsia.

[0133] As used herein, “high risk of pre-eclampsia” means a high risk of developing pre-eclampsia, but does not mean not currently having pre-eclampsia.

[0134] As used herein, “low risk of pre-eclampsia” means a low risk of developing pre-eclampsia, but does not mean not currently having pre-eclampsia.

[0135] "Pregnancy-related hypertensive disorders" means any condition or disorder during pregnancy that is associated with or characterized by elevated blood pressure. These conditions and disorders include pre-eclampsia (including pre-eclampsia of preterm birth and severe pre-eclampsia), eclampsia, gestational hypertension, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), placental abruption, chronic hypertension during pregnancy, pregnancy with intrauterine growth restriction, and pregnancy with small for gestational age (SGA).

[0136] As used herein, the term “soluble Flt-1 (sFlt-1)” (also known as soluble fms-like tyrosine kinase 1, sVEGF-RI) refers to a soluble form of the Flt-1 receptor that is homologous to the protein defined by GenBank accession number U01134 or UniProt P17948 or registered name VGFR1_HUMAN and possesses sFlt-1 bioactivity. The bioactivity of the sFlt-1 polypeptide can be assayed by assaying sFlt-1 binding to VEGF using any standard method. sFlt-1 lacks the transmembrane domain and cytoplasmic tyrosine kinase domain of the Flt-1 receptor. sFlt-1 can bind to VEGF and PlGF with high affinity but cannot induce proliferation or angiogenesis, and is therefore functionally distinct from Flt-1 and KDR receptors. sFlt-1 was initially purified from human umbilical cord endothelial cells and later shown to be produced in vivo by trophoblast cells. As used herein, sFlt-1 includes any sFlt-1 family member or isoform.

[0137] As used herein, the term “specifically binds” means a compound, antibody, or any detection reagent that recognizes and binds to a polypeptide (i.e., sFlt-1 or any fragment thereof) but substantially does not recognize and bind to other molecules in a sample (e.g., a biological sample naturally containing the polypeptide of sFlt-1 or any fragment thereof). In one embodiment, an antibody that specifically binds to sFlt-1 does not bind to Flt-1.

[0138] As used herein, “detection reagent” refers to a reagent suitable for determining the markers described herein, such as sFlt-1, PAPP-A, and PIGF. Such exemplary detection reagents are, for example, ligands that specifically bind to the peptide or epitope of the markers described herein, such as antibodies or fragments thereof. Such ligands may be used in immunoassays as described above. Further reagents used in immunoassays to determine the level of the markers may also be included in the kit and are considered detection reagents herein. Detection reagents may also relate to reagents used to detect the markers or fragments thereof by methods based on mass spectrometry. Therefore, such detection reagents may also be reagents used to prepare samples for MS analysis, such as enzymes, chemicals, buffers, etc. A mass spectrometer may also be considered a detection reagent. The detection reagent according to the present invention may also be, for example, a calibration solution that can be used to determine and compare the levels of the markers.

[0139] According to the present invention, the antibody may be a monoclonal antibody or a polyclonal antibody. In particular, an antibody that specifically binds to at least sFlt-1 or a fragment thereof is used.

[0140] An antibody is considered specific if its affinity for the target molecule, such as sFlt-1 or a fragment thereof, is at least 50 times higher, preferably 100 times higher, and most preferably at least 1000 times higher, than its affinity for other molecules in the sample containing the target molecule. How to develop and select antibodies with a given specificity is well known in the art. In the context of the present invention, monoclonal antibodies are preferred as detection reagents. The antibody or antibody-conjugated fragment specifically binds to the marker or fragment thereof as defined herein. In particular, the antibody or antibody-conjugated fragment binds to the sFlt-1 peptide as defined herein. Therefore, the peptide as defined herein may also be an epitope to which the antibody specifically binds. Furthermore, in the methods and kits of the present invention, antibodies or antibody-conjugated fragments that specifically bind to sFlt-1 or a fragment thereof are used.

[0141] Furthermore, the method and kit of the present invention use an antibody or antibody-conjugated fragment that specifically binds to sFlt-1 or a fragment thereof, and optionally specifically binds to other markers of the present invention, such as PAPP-A or PIGF.

[0142] Exemplary immunoassays may include luminescence immunoassays (LIAs), radioimmunoassays (RIAs), chemiluminescence and fluorescence immunoassays, enzyme immunoassays (EIAs), enzyme-linked immunoassays (ELISAs), luminescence-based bead arrays, magnetic bead-based arrays, protein microarray assays, rapid test formats, and rare-earth cryptotate assays. Furthermore, assays suitable for point-of-care testing and rapid test formats such as immunochromatography strip tests can be used. Automated immunoassays such as the B·R·A·H·M·S KRYPTOR assay are also intended.

[0143] Alternatively, other capture molecules or molecular scaffolds that specifically and / or selectively recognize sFlt-1 may be included in the scope of the present invention, instead of antibodies. In this specification, the terms “capture molecule” or “molecular scaffold” include molecules that can be used to bind to a target molecule or molecule of interest from a sample, i.e., an analyte (e.g., sFlt-1). Therefore, the capture molecule must be appropriately shaped spatially and with respect to surface features such as surface charge, hydrophobicity, hydrophilicity, Lewis donor and / or receptor presence or absence, and must specifically bind to the target molecule or molecule of interest. Thus, binding may be mediated by, for example, ions, van der Waals forces, π-π, sigma-π, hydrophobic or hydrogen bonding interactions, or a combination of two or more of the aforementioned interactions or covalent interactions between the capture molecule or molecular scaffold and the target molecule or molecule of interest. In the context of the present invention, the capture molecule or molecular scaffold may be selected from the group consisting of, for example, nucleic acid molecules, carbohydrate molecules, PNA molecules, proteins, peptides, and glycoproteins. Capture molecules or molecular scaffolds include, for example, aptamers, DAR pins (Designed Ankyrin Repeat Protein), and affimers.

[0144] The method according to the present invention can be further embodied as a homogeneous method, in which a sandwich complex formed by the antibody / multiple antibodies to be detected and a marker, sFlt-1 or a fragment thereof, remains suspended in the liquid phase. In this case, when two antibodies are used, it is preferable that both antibodies are labeled in part of the detection system so that a signal is generated or induced when both antibodies are combined into a single sandwich. Such techniques should be embodied in particular as fluorescence-enhanced or fluorescence-quenched detection methods. Particularly preferred embodiments relate to the use of detection reagents used in pairs, such as those described in US4882733, EP0180492, or EP0539477 and the prior art cited herein. Thus, it becomes possible to detect only the reaction product containing both labeled components directly in a single immunocomplex in the reaction mixture. For example, such techniques are offered as the trademark TRACE(trademark) (time-resolved amplification cryptotate release) or KRYPTOR(trademark), implementing the teachings of the applications cited above. Thus, in particularly preferred embodiments, a diagnostic device is used to carry out the methods provided herein. For example, the level of sFlt-1 or a fragment thereof, and / or the level of any further markers of the method provided herein, such as PAPP-A, PIGF, etc., is determined. In a particularly preferred embodiment, the diagnostic device is a B·R·A·H·M·S KRYPTOR.

[0145] In the embodiment, quantitative determination of sFlt-1 can be performed by the automated immunofluorescence assay B·R·A·H·M·S sFlt-1 KRYPTOR assay, preferably in conjunction with the B·R·A·H·M·S PlGF+KRYPTOR assay. The lower and upper detection limits of 22,000 and 90,000 pg / mL B·R·A·H·M·S sFlt-1 KRYPTOR provide the measurement range necessary for reliable detection of clinical sFlt-1 levels throughout pregnancy. Only 8 μL of serum sample isolated from the subject is required for the assay.

[0146] Those skilled in the art can obtain or develop means for the identification, measurement, determination, and / or quantification of any one of the above-described sFlt-1 molecules, or its fragments or variants, as well as other markers of the present invention in accordance with the biological practices of standard molecules.

[0147] The levels of the markers of the present invention, such as sFlt-1 or its fragments, PAPP-A or its fragments, or other markers, can also be determined by methods based on mass spectrometry (MS). Such methods may include detecting the presence, amount, or concentration of one or more modified or unmodified fragment peptides of, for example, sFlt-1 or PAPP-A, PIGF, in the biological sample or, for example, a protein digest from the sample (e.g., trypsin digest); optionally separating the sample using chromatography; and subjecting the prepared and optionally separated sample to MS analysis. For example, to determine the amount of sFlt-1 or its fragments in particular, selected reaction monitoring (SRM), multiple reaction monitoring (MRM), or parallel reaction monitoring (PRM) mass spectrometry may be used in the MS analysis.

[0148] In this specification, the terms “mass spectrometry” or “MS” refer to analytical techniques for identifying compounds by their mass. To enhance the mass resolution and mass determination capabilities of mass spectrometry, samples may be treated prior to MS analysis.

[0149] Accordingly, the present invention relates to an MS detection method, a sample preparation method, and / or a chromatography method that can be combined with immunoconcentration technology, preferably a method using liquid chromatography (LC), and more preferably a chromatography method using high-performance liquid chromatography (HPLC) or ultra-high-performance liquid chromatography (UHPLC).

[0150] Sample preparation methods include techniques for dissolution, fractionation, digestion of the sample into peptides, depletion, concentration, dialysis, desalting, alkylation, and / or peptide reduction. However, these steps are optional. Selective detection of analyte ions may be performed using tandem mass spectrometry (MS / MS). Tandem mass spectrometry is characterized by a mass selection step (as used herein, the term "mass selection" means the isolation of ions having a specific m / z or a narrow range of m / z / s), followed by fragmentation of the selected ions, and mass spectrometry of the resulting product (fragment) ions.

[0151] As used herein, the term "detection reagent that specifically binds to sFlt-1 and its fragments" means that the detection reagent recognizes and binds to the polypeptide and its fragments of sFlt-1, but does not substantially recognize and bind to other molecules in the sample, for example, a biological sample that naturally contains the polypeptide of sFlt-1.

[0152] Detection reagents for determining the level of sFlt-1 or its fragments, and optionally for determining the levels of PAPP-A, PIGF and / or its fragments, are preferably selected from what is necessary to carry out the method, such as an antibody directed to sFlt-1, a suitable label such as a fluorescent label, preferably two separate fluorescent labels suitable for use in the KRYPTOR assay, and a sample collection tube.

[0153] As used herein, the term "determining the level of sFlt-1 or its fragments in a sample" refers to any means of determining sFlt-1 or its fragments.

[0154] As used herein, “fragment” means a portion of a polypeptide or nucleic acid molecule. This portion preferably contains at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% of the total length of the reference nucleic acid molecule or polypeptide. The fragment may contain 10, 20, 30, 40, 50, 60, 70, 80, 90, or 100, 200, 300, 400, 500, 600, 700, 800, 813 or more nucleotides, or 10, 20, 30, 40, 50, 60, 70, 80, 90, 100, 150, 186, 200, 250, 271 or more amino acids. Preferred fragments have sFlt-1 biological activity.

[0155] The sensitivity and specificity of diagnostic and / or prognostic tests depend not only on the analytical "quality" of the test, but also on the definition of what constitutes an abnormal outcome. In practice, receiver operating characteristic curves (ROC curves) are typically calculated by plotting the values ​​of a variable against its relative frequency in a "normal" population (i.e., obviously healthy individuals who obviously do not have an infection) and a "disease" population, e.g., subjects with an infection. For any particular marker (such as sFlt-1), the distribution of marker levels for subjects with and without the disease / condition may overlap. Under such conditions, the test will not be able to perfectly distinguish between normal and disease with 100% accuracy, and the area of ​​overlap may indicate the portion where the test cannot distinguish between normal and disease. A threshold is selected below which the test is considered abnormal, above which the test is considered normal, or below or above which the test indicates a specific condition, e.g., infection. The area under the ROC curve is a measure of the probability that the perceived measurement would allow for the correct identification of the condition. ROC curves can be used even when test results do not necessarily give an exact number. As long as the results can be ranked, an ROC curve can be constructed. For example, the results of a test on a “disease” sample can be ranked according to degree (e.g., 1 = low, 2 = normal, and 3 = high). This ranking can correlate with the results of a “normal” population, and an ROC curve can be constructed. These advantages are well known in the art. See, for example, Hanley et al. 1982. Radiology 143:29-36. Preferably, the threshold is selected to provide an ROC curve area greater than about 0.5, more preferably greater than about 0.7, even more preferably greater than about 0.8, still more preferably greater than about 0.85, and most preferably greater than about 0.9. In this context, the term “about” refers to + / - 5% of a given measurement.

[0156] The horizontal axis of the ROC curve represents (1-specificity), which increases with the false positive rate. The vertical axis of the curve represents sensitivity, which increases with the true positive rate. Therefore, for a specific cutoff selected, the value of (1-specificity) may be determined, and a corresponding sensitivity may be obtained. The area under the ROC curve is a measure of the probability that the measured marker level will enable accurate identification of a disease or condition. For this reason, the area under the ROC curve can be used to determine the effectiveness of a test. AUC (area under the curve) facilitates the comparison of one ROC curve with another. ROC curves with a larger AUC represent logistic regression.

[0157] As used herein, terms such as “marker,” “surrogate,” “prognostic marker,” “factor,” or “biomarker” or “biological marker” are used interchangeably and relate to measurable and quantifiable biological markers (e.g., the concentration or fragment thereof of a particular protein or enzyme, the concentration or fragment thereof of a particular hormone, or the presence of a biological substance or fragment thereof) that serve as an index of health and physiological assessments such as disease / disability / clinical condition risk, preferably adverse events. A marker or biomarker is defined as a feature that can be objectively measured and evaluated as an indicator of a normal biological process, a pathogenic process, or a pharmacological response to a therapeutic intervention. Biomarkers may be measured in a sample (as in blood, plasma, urine, or tissue tests).

[0158] The stage of pregnancy at which the methods described herein may be implemented depends on various clinical factors, including the subject's overall health and the severity of pre-eclampsia symptoms.

[0159] In a particular embodiment, the method is performed on a subject by the end of the 12th week of gestation. The end of the 12th week of gestation means the last day of the 12th week of gestation, or the second to last day, the third to last day, or the fourth to last day of the 12th week of gestation.

[0160] In some embodiments, the method is performed on subjects at 9 weeks of gestation. In one embodiment, the method is performed at 10 weeks of gestation. In one embodiment, the method is performed at 11 weeks of gestation. In embodiments, the method is performed after 12 weeks of gestation. In embodiments, the method is performed at 13 weeks of gestation. In embodiments, the method is performed at 14 weeks of gestation. In embodiments, the method is performed in and around 15 and 20 weeks of gestation.

[0161] As used herein, “sample” means a body fluid sample, such as a blood sample, such as a venous blood sample, a capillary blood sample, a serum sample, a plasma sample, a vaginal fluid sample, a saliva sample, or an amniotic fluid sample, or cerebrospinal fluid, preferably a blood, serum, or plasma sample.

[0162] In the context of this invention, "plasma" refers to the substantially cell-free supernatant of blood containing an anticoagulant, obtained after centrifugation. Exemplary anticoagulants include calcium ion-binding compounds such as EDTA or citrate, and thrombin inhibitors such as heparinate or hirudin. Cell-free plasma can be obtained by centrifugating anticoagulated blood (e.g., citrate-treated, EDTA- or heparin-treated blood) at, for example, 2000-3000 g for at least 15 minutes.

[0163] In the context of this invention, "serum" refers to the liquid fraction of whole blood collected after blood coagulation. When coagulated blood (blood clot) is centrifuged, serum can be obtained as the supernatant.

[0164] "Sample" further refers to a tissue biopsy (e.g., placental tissue), chorionic villi sample, cells, or other specimen obtained from the subject. Preferably, the biological sample contains sFlt-1 nucleic acid molecules or polypeptides, or both.

[0165] As used herein, the term “reference sample” means any sample, standard, or level used for comparative purposes. A “normal reference sample” may be a previous sample taken from the same subject, a sample from a pregnant subject who has no pregnancy-related stress disorder such as pre-eclampsia or eclampsia, a pregnant subject from whom the sample was taken in the early stages of pregnancy (e.g., first or second trimester or before detection of pregnancy-related stress disorder such as pre-eclampsia or eclampsia), a pregnant subject with no history of pregnancy-related stress disorder such as pre-eclampsia or eclampsia, a non-pregnant subject, or a sample of purified reference polypeptide at a known normal concentration (i.e., not showing pregnancy-related stress disorder such as pre-eclampsia or eclampsia).

[0166] As used herein, the term “reference level” refers to a value or number derived from a reference sample. A normal reference standard or level may be a value or number derived from a normal subject. Preferably, all reference samples, standards, and levels are fitted to the sample subject by at least one of the following criteria: fetal age at conception, maternal age, maternal blood pressure before pregnancy, maternal blood pressure during pregnancy, maternal BMI, fetal weight, previous diagnosis of pregnancy-related hyperkinesthetic disorder, and family history of pregnancy-related hyperkinesthetic disorder.

[0167] In one embodiment, the reference level relates to a value derived from a pregnant subject who has not developed pre-eclampsia or pregnancy-related hyperkinesthetic disorders (e.g., in the first or second trimester, or before pregnancy-related hyperkinesthetic disorders such as pre-eclampsia or eclampsia are detected).

[0168] In the embodiment, the reference level refers to a value derived from a pregnant subject who does not have a history of pregnancy-related hypertensive disorders such as pre-eclampsia or eclampsia.

[0169] In one embodiment, the reference levels and levels from the subject to be determined as used herein preferably refer to measured levels of sFlt-1 or its fragments in blood samples, preferably whole blood samples or plasma or serum samples, obtained from pregnant subjects who have not developed pre-eclampsia, using the Thermo Scientific B·R·A·H·M·S KRYPTOR assay. Therefore, the values ​​disclosed herein may vary to some extent depending on the detection / measurement method used, and specific values ​​disclosed herein are also intended to be read as corresponding values ​​determined by other methods. In embodiments of the present invention, a decrease in the level of sFlt-1 or its fragments compared to a reference level that can define a transition from low-risk to high-risk for developing PE may be any decrease in the range of 6% to 20% compared to the reference level. Any value within this range can be considered a suitable reference level for high and low-risk sFlt-1 levels. Furthermore, values ​​below such reference levels may indicate a high risk of pre-eclampsia, and values ​​above such reference levels may indicate a low risk of pre-eclampsia. Suitable cutoff levels that may be used in the context of the present invention include, but are not limited to, changes of at least 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, or 25% compared to the reference level.

[0170] As used herein, the terms “positive reference” sample, standard, or value are samples, values, or numbers derived from subjects known to have or have had pregnancy-related hyperkinesthetic disorders, such as pre-eclampsia or eclampsia. Reference standards or levels may also, depending on the context, reflect the mean or average levels of nucleic acids, polypeptides, or small molecules from normal or positive reference subjects. References may also be charts, graphs, or standard curves representing normal reference levels of polypeptides, nucleic acids, or small molecules at any and / or all stages of pregnancy (e.g., weekly). Preferably, all reference samples, standards, and levels are fitted to the sample subject by at least one of the following criteria: fetal age at gestation, maternal age, maternal blood pressure before pregnancy, maternal blood pressure during pregnancy, maternal BMI, fetal weight, previous diagnosis of pregnancy-related hyperkinesthetic disorders, and family history of pregnancy-related hyperkinesthetic disorders.

[0171] As used herein, the term “history of pregnancy-related hypertension” means a prior diagnosis of a pregnancy-related hypertension (e.g., pre-eclampsia or eclampsia or gestational hypertension) in the subject or a related family member.

[0172] As used herein, “gestational age” refers to the age of the fetus counted from the first day of the mother’s last menstrual period. It also refers to the corresponding gestational age estimated by more precise methods in the art. In the case of in vitro fertilization, it is 14 days in addition to the known period from fertilization. Gestational age can be determined by obstetric ultrasound.

[0173] As used herein, “maternal age” means the age of the pregnant woman at the time of childbirth.

[0174] As used herein, the term “gestational hypertension” means the onset of hypertension without proteinuria after 20 weeks of gestation.

[0175] As used herein, the term "polypeptide" refers to a polymer of amino acids and not to a specific length. Therefore, peptides, oligopeptides, and proteins are included within the definition of polypeptide.

[0176] The term "including" is used herein to mean the phrase "including, but not limited to," and is interchangeable with it.

[0177] The term "etc." is used herein to mean the phrase "etc., but not limited to," and is used interchangeably with it.

[0178] As used herein, the terms “risk parameter” or “risk factor” refer to health conditions that predispose the pregnant subject to developing pre-eclampsia. One risk parameter is the parent’s blood type, preferably the biological father’s or biological mother’s AB blood type. A more preferred blood type is the parent’s Rh factor, particularly if the pregnant subject is Rh-negative and the fetus’s biological father is Rh-positive. Risk parameters include, but are not limited to, hypothyroidism, hyperthyroidism, BMI greater than 24, primiparous pregnancy, history of pre-eclampsia, ethnicity with risk disorders, multiple pregnancy, migraine, lupus, blood clotting disorders, e.g., hypercoagulation, inflammatory diseases, cardiac predisposition, diabetes mellitus, chronic kidney disease, and chronic hypertension.

[0179] The methods described herein, and levels of sFlt-1 below the reference level, indicate initiating or modifying the treatment of the subject to reduce the risk of developing pre-eclampsia, delay the onset of pre-eclampsia, or at least reduce the severity of pre-eclampsia, such as by balancing the angiogenic / anti-angiogenic processes in placental development, lowering blood pressure, or protecting organ function from the kidneys or liver.

[0180] In embodiments, levels of sFlt-1 below the reference level indicate initiating or modifying targeted treatment to reduce the risk of developing pre-eclampsia, delay the onset of pre-eclampsia, or at least reduce the severity of pre-eclampsia, such as balancing angiogenesis / anti-angiogenesis processes in placental development, lowering blood pressure, or protecting organ function from the kidneys or liver. Such treatments may also involve prenatal monitoring, lifestyle modifications, nutritional supplements, bed rest, restriction of activity or regular exercise, reduction of salt intake, and antioxidants such as vitamins C and E, garlic, and fish oil.

[0181] As used herein, the term “never given birth” means that the subject has never given birth. “First birth” means that the subject has given birth once, and “biparous” means that the subject has given birth twice. “Multiple births” means that the subject has given birth more than twice.

[0182] As used herein, the term “chromosomal abnormality” means any difference in chromosomes that may occur during fetal development. These may be unique to the fetus or inherited from the parents. Abnormalities fall into two categories: numerical, which refers to a different number of chromosomes than expected, such as monosomy or trisomy; and structural, which refers to translocations, deletions, duplications, ring formation resulting from the splitting of a portion of a chromosome, and chromosomal inversions. Examples of chromosomal abnormalities include, but are not limited to, Down syndrome, Turner syndrome, Klinefelter syndrome, trisomy 13, trisomy 14, triple X syndrome, XYY syndrome, fragile X syndrome, and Cri-Du-Chat syndrome.

[0183] The present invention further relates to kits, uses of kits, and methods by which such kits are used. The present invention relates to kits for carrying out the methods provided above and below herein. The definitions provided herein, for example, the definitions provided with respect to methods, also apply to the kits of the present invention. The kit may also be part of a medical device that also contains a calibrator, a control, a buffer reagent, and can be used in connection with a diagnostic instrument and / or software. In particular, the present invention relates to a kit for therapeutic monitoring, including prognosis, risk assessment, or risk stratification of subsequent adverse events in a patient's health, the kit comprising a detection reagent for determining the level of sFlt-1 or fragments thereof, and optionally additional reagents for determining the level of further biomarkers in a sample from a subject, and reference data such as sFlt-1 risk levels and optionally reference levels corresponding to further biomarker levels, the reference data preferably stored on a computer-readable medium and / or used in the form of computer-executable code configured to compare the determined levels of sFlt-1 or fragments thereof and optionally further determined levels of further biomarkers or fragments thereof with the reference data.

[0184] In one embodiment of the method described herein, the method further includes comparing a determined level of sFlt-1 or a fragment thereof with a reference level, threshold, and / or a population mean corresponding to sFlt-1 or a fragment thereof in patients at risk of developing PE, wherein such comparison is performed on a computer processor using computer executable code.

[0185] The method of the present invention can be partially performed by computer. For example, the step of comparing the detected level of a biomarker, e.g., sFlt-1 or a fragment thereof, to a reference level can be performed by a computer system. In the computer system, the determined level of the biomarker can be combined with other biomarker levels and / or clinical parameters of interest to calculate a score, which is an index for prognosis, risk assessment, and / or risk stratification. For example, the determined values ​​can be entered into the computer system (either manually by a healthcare professional or automatically from the device on which each marker level was determined). The computer system may be directly at the point of care (e.g., primary care, hospital, or home environment) or in a remote location connected via a computer network (e.g., via the Internet, or optionally via a specialized medical cloud system that can be combined with other IT systems or platforms such as hospital information systems (HIS)). Typically, a computer system stores values ​​(e.g., biomarker levels, or clinical parameters such as age, blood pressure, weight, sex, or pregnancy parameters such as UAPI, FMF algorithms, or scores such as VOCAL score, BMI, etc.) in a computer-readable medium and calculates scores based on predefined and / or pre-stored reference levels or reference values. The resulting scores are displayed and / or printed for the user (typically a healthcare professional such as a physician or patient). Alternatively, or in addition, relevant prognoses, assessments, treatment guidelines, patient management guidelines, or stratification are displayed and / or printed for the user (typically a healthcare professional such as a physician or patient).

[0186] In one embodiment of the present invention, preferably, a software system can be used in which a machine learning algorithm exists to identify patients at risk of PE using data from electronic health records (EHRs). The machine learning approach can be trained on a random forest classifier using EHR data from patients (e.g., test results, biomarker expression, vital signs, demographics). Machine learning is a type of artificial intelligence that, unlike simple rule-based systems, gives computers the ability to learn complex patterns in data without being explicitly programmed. Previous research has used electronic health record data to trigger alerts and detect common clinical deteriorations. In one embodiment of the present invention, sFlt-1 level processing can be incorporated into appropriate software for comparison with existing datasets, for example, sFlt-1 levels can be processed in machine learning software that assists in prognostic diagnosis of PE occurrence.

[0187] "PAPP-A" refers to pregnancy-related plasma protein A, paparin-1, a plasma protein used as a screening test between weeks 8 and 14 of gestation. Reduced levels of this protein suggest an increased risk of Down syndrome, intrauterine growth restriction, pre-eclampsia, and stillbirth.

[0188] PlGF is a placental growth factor (UniprotKB-Q6IB04) that is a member of the vascular endothelial growth factor (VEGF) family. PlGF is involved in the glycosylphosphatidylinositol-alcohol biosynthesis pathway, which is part of glycolipid biosynthesis. PlGF levels are decreased in pregnant women who are expected to develop pre-eclampsia.

[0189] When used herein, the reference data includes, for example, patient groups with maternal age up to 18, between 18 and 34, and over 34, optionally, reference levels corresponding to additional markers described herein, preferably PAPP-A and / or PIGF levels, the reference data preferably stored on a computer-readable medium and / or used in the form of computer-executable code configured to compare the determined levels of sFlt-1 or fragments thereof, optionally, in addition, determined levels of PIGF or fragments thereof, and optionally, further determined levels of PAPP-A and / or PIGF or fragments thereof with the reference data. The "reference date" includes further reference levels corresponding to patient groups having blood type AB, having blood type Rh negative, having blood type Rh negative and fetal biological father Rh positive, being pregnant with at least one female fetus, being pregnant with at least one male fetus, being nulliparous, having one or more previous pregnancies, and / or suspected of being pregnant with a fetus with a chromosomal abnormality. The reference data may also include instructions for using the kit of the present invention.

[0190] The kit may further include items useful for obtaining samples such as blood samples, for example, the kit may include a container, which includes a device for attaching the container to a cannula or syringe, which is suitable for blood isolation and exhibits an internal pressure lower than atmospheric pressure, for example, for drawing a predetermined volume of sample into the container, and / or a chelating agent such as surfactants, chaotropic salts, ribonuclease inhibitors, guanidinium isothiocyanate, guanidinium hydrochloride, sodium dodecyl sulfate, polyoxyethylene sorbitan monolaurate, RNAse inhibitory proteins and mixtures thereof, and a filter system including nitrocellulose, silica matrix, ferromagnetic spheres, cup recovery spillover, trehalose, fructose, lactose, mannose, polyethylene glycol, glycerol, EDTA, TRIS, limonene, xylene, benzoyl, phenol, mineral oil, aniline, pyrrole, citrate and mixtures thereof. The present invention will be further illustrated with reference to the drawings, which are not intended to limit the scope of the invention. [Brief explanation of the drawing]

[0191] [Figure 1] These box plots show sFlt-1 levels before 90 days gestation, between 90 and 100 days gestation, or between 140 and 154 days gestation, comparing levels in subjects with and without EO-PE. The study included 11,952 women recruited in Phase 1, 11,918 without PE, and 34 with early-onset PE. Before 90 days gestation, all women with EO-PE (N=10) had sFlt-1 levels below the median (p<0.01). On average, between 90 and 100 days gestation, all women with EO-PE (N=24) had sFlt-1 levels above the median. Between 140 and 154 days gestation, all women with EO-PE (N=4) had sFlt-1 levels above the median. [Figure 2] This is a statistical evaluation of sFlt-1 levels in subjects from whom samples were obtained in Phase 1. The study included 11,952 women recruited in Phase 1, 11,918 without PE, and 34 with early-onset PE. As can be observed, SFlt-1 in Phase 1 was not associated with EO-PE (EO-PE: 0.98 MoM vs. control: 1.00 MoM, p=0.09). [Figure 3] This study statistically evaluated sFlt-1 levels in subjects whose samples were obtained 12 6 / 7 weeks after gestational age (GA). The study included 7409 women recruited at 90 days gestation, 7385 without premature PE and 24 with premature PE. As can be observed, sFlt-1 at 12 6 / 7 weeks was not associated with EO-PE (EO-PE: 1.00 MoM vs. control: 1.00 MoM, p=0.40). [Figure 4] Figure 3 shows the ROC curve for the data presented, which indicates that sFlt-1 after 6 / 7 weeks is not associated with EO-PE. [Figure 5]This study statistically evaluates sFlt-1 levels in subjects whose samples were obtained 12 6 / 7 weeks before gestational age (90 days before gestational age). The study included 4543 women recruited 90 days before gestation, 4533 without premature pulmonary embolism (PE), and 10 with premature PE. As can be observed, sFlt-1 at 12 6 / 7 weeks was inversely correlated with EO-PE (EO-PE: 0.94 MoM vs. control: 1.00 MoM, p=0.003). [Figure 6] Figure 5 shows the ROC curve of the data presented, demonstrating that sFlt-1 measured 6 / 7 weeks prior correlates with EO-PE. Both sFlt-1 (adjusted for gestational age-MoM) and sFlt-1 (not adjusted for gestational age-birth) measurements predict early PE and can be used as markers for early PE (AUC: 0.74 (95% CI: 0.64~0.84, p<0.01)). [Figure 7] This is a ROC curve of data for sFlt-1 and PlGF levels in subjects whose samples were obtained 12 weeks 6 / 7 after GA (90 days after GA). At 90 days of gestation, PlGF is a strong marker for EO-PE, but sFlt-1 is not. [Figure 8] These are ROC curves for sFlt-1 and PlGF levels in subjects whose samples were obtained 12 weeks 6 / 7 before GA (90 days before GA). 90 days before gestation: sFlt-1 is a strong marker for EO-PE, but PlGF levels are not as good as at 90 days. [Figure 9] These are ROC curves for data on sFlt-1 and PlGF levels in subjects whose samples were obtained 12 6 / 7 weeks before GA (90 days before GA). Furthermore, the ROC curves are shown using combined data for both sFlt-1 and PlGF levels. The ROC curves show AUC values ​​for PlGF: 0.70 (95% CI: 0.56-0.85), sFlt-1: 0.74 (95% CI: 0.64-0.84), and a combination of both markers: 0.85 (95% CI: 0.78-0.92). [Figure 10]These are ROC curves for sFlt-1 and PlGF levels in subjects whose samples were obtained 12 weeks 6 / 7 before GA (90 days before GA). Furthermore, uterine artery Doppler measurement data obtained in this study were combined into the analysis. The ROC curves are shown using combined data for both sFlt-1 and PlGF levels, and these combined levels are further combined with the Doppler data. The ROC curves show an AUC value of 0.87 (95% CI: 0.80-0.94) for the Doppler combination. [Figure 11] This is a ROC curve of data for sFlt-1 and PlGF levels in subjects whose samples were obtained between 90 and 100 days of GA. The combination of sFlt-1 and PlGF predicts several cases of IUFD between 90 and 100 days. [Figure 12] This is a ROC curve of data for sFlt-1 and PlGF levels in subjects whose samples were obtained 90 days before gestational age (GA). The combination of sFlt-1 and PlGF predicts IUFD, and thus the association is stronger 90 days before gestation compared to 90-100 days before gestation (AUC: 0.72 95%, CI: 0.60-0.84). [Figure 13] These are box plots and ROC curves showing the correlation between sFlt-1 levels (measured 90 days prior to GA) in subjects with estimated high or low risk as determined using the FMF algorithm. As can be seen from the figures, patients with high risk as determined by the FMF algorithm have significantly lower sFlt-1 levels prior to 90 days prior to GA. [Examples]

[0192] Example 1: Research design: Pregnant women were recruited between 11 and 14 weeks of gestation and followed until delivery. sFlt-1 was measured at recruitment using a Thermo Scientific BRAHMS KRYPTOR and reported as a multiple of the median (MoM) adjusted for gestational age. Median sFlt1 levels were compared among women who experienced early-onset PE (<34 weeks), mid-trimester PE (34-36 weeks), late-onset PE (≥37 weeks), and no PE (control). The area under the ROC curve (AUC) was used to estimate the potential predictor of sFlt-1 for PE.

[0193] result: We included 12,383 participants who gave birth after 16 weeks of gestation, of whom 33 (0.3%) developed early-onset pulmonary embolism (PE), and 65 (0.5%) and 400 (4.0%) developed late-onset PE. We observed that the first-stage sFlt-1 score was lower in participants who developed early-onset or mid-onset PE (p=0.02), but more importantly, the difference was observed to be mainly present in participants recruited in the early stages of pregnancy.

[0194] Significant differences in the predicted value of early-onset PE were observed among women recruited at 11 weeks of gestation (AUC: 0.82, 95% CI: 0.72-0.92, p<0.001) and 12 weeks of gestation (AUC: 0.62, 95% CI: 0.49-0.74; p=0.06), and were observed at 13 weeks of gestation (AUC: 0.50, 95% CI: 0.32-0.67, p=0.97). A similar trend was observed in the prediction of mid-term onset PE.

[0195] Conclusion: Maternal sFlt-1 levels in the first trimester decrease in women who develop PE before the end of the term (<37 weeks). This predictive value is significantly improved when collected at or before 12 weeks of gestation, a peculiarity that may explain the conflicting results between previous studies.

[0196] Example 2: Research design: We conducted a secondary analysis of a prospective cohort study of nulliparous women recruited between 11 and 14 weeks of gestation. Maternal characteristics, mean arterial blood pressure, maternal serum biomarkers (pregnancy-related plasma protein-A, placental growth factor, two risk cutoffs (1 / 70 and 1 / 100 from the FMF algorithm), sFlt-1, and mean uterine artery pulse index) levels were obtained to calculate the risk of early-onset and late-term PE compared to a reference group that did not develop early-onset or late-term PE. Detection rates, false-positive rates, and positive and negative predictive values ​​were calculated and determined for late-term and early-term PE as placental complications. Women who reported taking aspirin daily were excluded. PAPP-A, PIGF, and sFlt-1 concentrations were measured using the Thermo Scientific BRAHMS KRYPTOR automated assay. Early-onset PE was defined as PE delivered before 37 weeks of gestation, and early-onset PE refers to cases delivered before 34 weeks of gestation. The analysis was performed using the SAS statistical software package (version 9.3, SAS Institute). The analysis was performed using (Cary, NC). A 5% Type I error was considered in all analyses.

[0197] result: We included 4575 participants with complete observation. 29 patients developed early-onset PE, while 194 women developed late-term PE, and 3705 women did not develop placental complications (reference group). The median sFlt-1 value in the reference group was 1023 pg / mL, and Q1-Q3 values ​​ranged from 771 to 1373 pg / mL. The median sFlt-1 value and Q1-Q3 values ​​for women with onset PE were 933 pg / mL (726-1221 pg / mL). Therefore, pregnant women who developed full-term PE showed an 8.8% decrease in median sFlt-1 levels and a 0.91 fold change (FC) in median sFlt-1 levels.

[0198] The median sFlt-1 levels and Q1-Q3 values ​​for women with early-onset premature pulmonary embolism (PE) were 852 pg / mL (658-1095 pg / mL). Therefore, pregnant women with early-onset PE showed a higher sFlt-1 decrease compared to the reference group, with a median sFlt-1 decrease of 16.7% between weeks 11 and 14 of gestation and a median multiple of 0.83 (FC) change, classifying them as a late-stage PE group.

[0199] Compared to the reference group, the sFlt-1 level Q1 in early-onset PE showed a 14.7% decrease, with a FC of 0.85.

[0200] Compared to the reference group, the Q1 sFlt-1 level in the final PE showed a decrease of 5.8% with a FC of 0.94.

[0201] Compared to the reference group, the Q3 sFlt-1 level in early-onset PE showed a 20% decrease, with an FC of 0.8.

[0202] Compared to the reference group, the Q3 sFlt-1 level in the final PE group showed a decrease of 11% and a FC of 0.89.

[0203] Conclusion: Numerous women with a median decrease in sFlt-1 detected between weeks 11 and 14 of gestation are at higher risk of developing end-term PE, and those with a median decrease in sFlt-1 of at least 16.7% are at higher risk of developing early-onset PE.

[0204] Example 3: Prediction of premature eclampsia and preterm birth in the first trimester of pregnancy (predictive study): Preeclampsia is a pregnancy complication affecting 2–5% of pregnant women. It is one of the leading causes of maternal and neonatal mortality and morbidity worldwide. Premature preeclampsia requires delivery before 34 weeks of gestation and is associated with a very high perinatal morbidity rate.

[0205] Online software (Fetal Medicine Foundation) combining biophysical factors (age, BMI, BP, medical history), ultrasound factors (uterine artery Doppler), and biochemical factors (PlGF and PAPP-A) measured during the first trimester of pregnancy is now available and suggests that over 90% of early pre-eclampsia can be predicted with a false-positive rate of less than 10%.

[0206] To explore the correlation between biomarkers such as sFlt-1, PAPP-A, or PlGF and pre-eclampsia, this discovery study will further include additional patient groups, such as patients under 18 years of age who have several rare blood types (including AB, Rh-negative), have had or are experiencing multiple pregnancies, have had one or more previous pregnancies, have malformations or polydysplasia syndromes, and / or are suspected of or are carrying a fetus with a chromosomal abnormality (very high nuchal permeability).

[0207] the purpose: 1) Validate the FMF screening tool between weeks 11 and 13 of pregnancy for premature pre-eclampsia and other placenta-related pregnancy complications (premature pre-eclampsia, IUGR < 3rd percentile, perinatal mortality). 2) Compare screening tools that use uterine artery Doppler measurement with those that do not. 3) Investigate the efficacy of potential markers for predicting pre-eclampsia (serum sFlt-1, serum ADAM-12, serum PP-13, placental and subplacental volume, placental vascular distribution).

[0208] Methodology: This was a prospective observational study. Numerous women with one previous pregnancy and a fetus free of lethal abnormalities were recruited between weeks 113 / 7 and week 136 / 7 of pregnancy. A lifestyle questionnaire was completed. BMI and blood pressure measurements were taken, and blood samples (20 mL) were collected. Doppler ultrasound of the uterine arteries and 3D evaluation of the placenta were performed upon arrival at the hospital. Medical records were followed up approximately one month after the expected delivery date.

[0209] Serum was analyzed using the Thermo Scientific B·R·A·H·M·S KRYPTOR automated assay within 10 days of recruitment for PAPP-A, PIGF, sFIt1, fbHCG, and AFP. The remaining serum was stored at -80°C at the end of the project for further analysis (PP-13, ADAM-12, vitamin D) to assess the potential to improve predictive models using promising markers, including placental volume and vascular distribution assessed by 3D ultrasound. For each participant, the risk of early pre-eclampsia and overall pre-eclampsia was calculated using FMF software and disclosed to the participant. The optimal sensitivity and specificity of the tool were evaluated using ROC curves.

[0210] We estimated a 0.7% incidence of pre-eclampsia (<34 weeks) in our nulliparous population (Quebec and Montreal). We recruited 7,554 women and demonstrated that the FMF screening tool is at least 80% sensitive and 90% specific, when it is expected to be 95% sensitive and 92% specific.

[0211] the purpose Main purpose We will validate the FMF early pre-eclampsia screening tool between weeks 11 and 13 of pregnancy.

[0212] secondary purpose 1) Evaluate the performance of the FMF trial in predicting all cases of pre-eclampsia and other placenta-related pregnancy complications (early and severe pre-eclampsia, IUGR < 3rd percentile, perinatal mortality). 2) Compare screening tools with and without uterine artery Doppler imaging. 3) If the FMF screening tool is not positively validated in our population, we will individually evaluate the predicted values ​​of each biomarker and assess whether they can be used in different predictive models. 4) Evaluate the predictive values ​​of potential biomarkers for pre-eclampsia (sFlt-1, PP13, ADAM-12, 25-OH-vitamin D, placental volume and placental / subplacental vascular distribution, sFlt-1). 5) To evaluate the predictive value of cervical measurements in the first trimester of pregnancy for early delivery.

[0213] I. Research citation This was a prospective observational study of nulliparous pregnant women recruited during the first trimester of pregnancy. At that time, numerous biomarkers were collected and analyzed, and the participants were followed until delivery to verify the existence of our primary and secondary outcomes.

[0214] II. Groups and Selection Criteria Research set of inclusion criteria: • Live singleton pregnant women between week 3 / 7 of week 11 and week 6 / 7 of week 13. • Numerous women (who have no history of pregnancy up to 20 / 7 weeks of gestation, regardless of the reason)

[0215] Exclusion criteria study set: Girls under 18 • Women who are unable to give informed consent (e.g., those who do not understand English or French). • Women who planned to give birth outside of the participating centers (excluding women who gave birth at Hotel-Dieu de Levis and were eligible for the project because they agreed to have their files reviewed at this institution via a consent form). • Women who are positive for HIV, hepatitis C, or chronic hepatitis B (and have not been cured)

[0216] Further research sets on inclusion criteria: • Multiple pregnancies (women carrying two fetuses, one of which has stopped growing, are not eligible) • Presence of fetal malformation syndrome or multiple malformation syndrome • The presence of nuchal translucency measurements greater than 3.5 mm, which may affect serum PAPP-A levels and are associated with a very high risk of chromosomal abnormalities and / or cardiac malformations. • Fetal heart test negative on the day of the recruitment visit.

[0217] Conducting a print research project. 11 3 / 7 week ~ 13 6 / 7 week Visits addressed to nurses (11 March 7th week ~ 13 June 7th week) First, the research nurse collected a blood sample by venipuncture (2 x 5 mL tube, BD Vacutainer SST). The tube was gently inverted five times to thoroughly mix the reagent with the blood. The tube was left upright in a dark box until treatment (minimum 30 minutes, maximum 2 hours). In the second step, the research nurse measured the patient's blood pressure. The patient had to sit still with non-crossed legs for 5 minutes without speaking before measurement. Blood pressure was measured three times simultaneously on both arms (sleeveless vest) using a pre-programmed Microlife electrovascular blood pressure monitor (model 33603).

[0218] A questionnaire was administered to the patient to gather information about their medical history, obstetric family history, and socioeconomic background, including date of birth, anthropometric measurements, and tagabism (see attached questionnaire). Total visits with nurses were limited to a maximum of 30 minutes.

[0219] Visits for technicians (Week 11, 3 / 7 to 13, 6 / 7) Following a meeting with a nurse, all patients were interviewed by the research team's radiologists and certified for nuchal translucency measurements to perform ultrasound acquisition using a Voluson E8 Expert (GE Medical Systems, Milwaukee, WI, USA) equipped with a 4-8 MHz transducer. The instrument settings were the same for all patients, i.e., "Angiomode" = 100, "Smoothness" = 4 / 5, "FRQ" = Low, "Quality" = Normal, "Density" = 6, "Enhancement" = 16, "Balance" = 175, "WMF" = Low 1, "Actual Power" = 2 dB, "Pulse Repetition Frequency" = 0.6 kHz, Gain Color = -7.2 dB.

[0220] We conducted an ultrasound to verify the project's eligibility criteria. 1) If the cephalocaudal length (CCL) is 77 mm or more, the gestational age is determined using the cephalocaudal length (CCL) and vertebral diameter. 2) Nuchal translucency measurements were performed according to the standards of the Fetal Medicine Foundation. If a participant had a prescription for nuchal translucency measurement, a report with the results was provided. 3) If malformation syndrome, multiple pregnancy, nuchal translucency ≥ 3.5 mm and / or fetal cardiac negativity are present, the patient will be notified and may be examined by one of the physicians in charge of the project or their representative. An ultrasound report with the results will be sent to the patient's commissioning physician.

[0221] The technicians completed the eligibility sheets accordingly. Participants who met at least one of the exclusion criteria were treated as any other participant; that is, their blood samples were analyzed, and all data already collected or planned to be collected before delivery was retained. All data from these participants were excluded from the primary analysis.

[0222] The visit window between weeks 11 (3 / 7) and 13 (6 / 7) of pregnancy is important and respected to ensure the validity of certain data (biochemical and ultrasound). Therefore, when ultrasound dating confirms gestational age, the following applies:

[0223] a) <11 3 / 7 Week (LCC < 45 mm): Visits were rescheduled to a day between week 11 3 / 7 and week 13 6 / 7. Blood sampling and ultrasound were repeated at this time. Both samples were retained, but only the second sample was used for the primary analysis. If the minimum number of these patients (n ≥ 5) showed early pre-eclampsia, the first sample was analyzed and compared to the second sample in a case-control study.

[0224] Participants' wishes regarding whether or not to return for a follow-up visit were respected. If a participant refused a second visit, the collected data was retained but excluded from the primary analysis. b) >14 weeks (CCL > 84 mm): Blood samples, ultrasound data, and questionnaire data were retained as is. No further visits were scheduled. These patients were excluded from analysis for the primary purpose.

[0225] Next, the following ultrasonic measurements were performed for research purposes. 4) Doppler ultrasound was used to visualize the left and right uterine arteries, and the pulsation index was measured according to the FMF criteria. The uterine arteries were examined at the level of the internal tibia, and the pulsation index was automatically calculated by machine using pulsatile flow curves of three subsequent similar cardiac cycles. Measurements were performed in the sagittal and transverse directions, and the difference between the two techniques was evaluated in approximately 1000 samples to assess the reproducibility, duration, and efficiency of the two techniques. The presence or absence of notches was recorded bilaterally (notches are considered to be present if early diastolic incision occurs in each cycle). 5) 3D ultrasound examination of the placenta and subplacental region with and without Doppler. This examination takes approximately 30 seconds.

[0226] At the end of recruitment, for case-control analysis, technicians who were not informed of the clinical data performed the following volumetric measurements and calculations. Using VOCAL (Virtual Organ Computer-aided Analysis) and a series of six placental sections rotated 30 degrees horizontally from the front on planes A and B, the placental contour was manually drawn, taking care to exclude the uterine wall. Similarly, the volume of the subplacental myometrium was assessed from the boundary between the placenta and the duodenal myometrium to the total thickness of the myometrium (maximum 1 cm thickness). These volumetric measurements were obtained using the following variables: a. Placental volume b. Placental quotient (PQ=1 / 4% placental volume / LCC). c. The vascularity index (VI), flow index (FI), and vascular flow index (VFI) of the placenta and duodenal-myometrium region are evaluated using VOCAL software. VFI represents the number of stained voxels in the studied volume (expressed as a percentage). FI is the average color value of all stained voxels representing the average blood flow intensity (expressed as an absolute value from 0 to 100). VIF is the average color of all voxels in the studied region (gray and colored, expressed as an absolute value from 0 to 100). 6) Cervical length: vaginal (intravaginal probe). This test, performed only at the CHU in Quebec City, validated the prediction of premature birth, which is also present in the FMF algorithm. This was not performed systematically on all participants, but was performed at the discretion of the attending physician. 7) An ultrasound examination of the abdominal region was also performed to inductively measure the thickness of visceral adipose tissue between the medial boundary of the rectus abdominis muscle and the anterior wall of the abdominal aorta. This ultrasound measurement may have greater predictive power than BMI in predicting pre-eclampsia. The acquisition time is only a few seconds.

[0227] The total time required to acquire all ultrasound measurements was 15-35 minutes. Research technicians were certified and authorized by the Fetal Medicine Foundation (FMF) and PQDT21 for nuchal translucency and cervical measurements. Participants received a DVD or USB stick containing fetal images as a token of appreciation for their participation.

[0228] Pregnancy monitoring (34 0 / 7 weeks ~ 35 6 / 7 weeks) The survey (in electronic format, sent to participants via email) will be conducted on Pregnancy No. 34. eThe survey was conducted weekly. This involved verifying whether the patient's medication had changed during pregnancy and confirming whether the pregnancy was progressing normally, had shifted, or had experienced any complications to date. If the survey was not completed, an email reminder was automatically sent after one week. Subsequently, telephone calls were made to those who had not responded to the survey.

[0229] Postpartum follow-up (6 weeks after DPA) A second electronic survey (sent via email to participants) was conducted approximately six weeks after the participant's expected delivery date. This allowed us to verify whether the participant or their infant experienced any difficulties after birth. In particular, we wanted to know about cases of postpartum pre-eclampsia and rare cases of perinatal or maternal death (regardless of the hospital in which these events occurred). If the survey was not completed, an email reminder was automatically sent one week later. Subsequently, telephone calls were made to those who did not respond to the survey. To avoid inconvenience, measures were taken to ensure that participants who had terminated, experienced intrauterine death, or had other adverse complications (as mentioned in the 34-week survey) were not contacted again at 46 weeks unless necessary.

[0230] Follow-up study at the end of pregnancy (one month after DPA) Data regarding pregnancy (e.g., gestational hypertension, pre-eclampsia, perinatal death), delivery (e.g., gestational age), and neonatology (e.g., sex, birth weight) were collected post-delivery by research nurses from patients' medical records via CristalNet software. In the rare event that a patient delivered at a non-participating center (not CHUL, HSFA, or Levis), the patient was contacted to request permission to obtain this information at the place of delivery. For all cases suspected of having pre-eclampsia and cases delivered before 37 weeks (<10%, i.e., fewer than 532 records retrieved from the CHU-Q archive and fewer than 228 records retrieved from the CHUSJ archive), a second review of the data was performed by a physician (EB, KG, FA, or their representative) directly from the medical records.

[0231] Blood sample Blood samples were transported to the laboratory in a room-temperature box and centrifuged less than two hours after puncture but more than 30 minutes after puncture.

[0232] After centrifugation (1200 × g, 10 minutes at room temperature), the collected serum was transferred to a 1 mL aliquot and then used to measure PAPP-A, PIGF, sFlt-1, free bHCG, and maternal serum AFP using a commercially available kit validated by FMF. For CHU de Quebec (CHUL and HSFA), samples were stored at 4°C until the assay was performed within 24 hours. For CHU Ste-Justine, aliquots were stored at -20°C and sent to CHU de Quebec twice a month by registered mail on dry ice for analysis and storage. After the primary analysis (serum PAPP-A, PIGF, and sFlt-1 assays), the remaining serum was frozen and stored at -80°C and used to measure PP13, ADAM12, and vitamin D in a case cohort secondary study conducted at the end of the main study.

[0233] Case cohort study A case cohort study nested within the main cohort evaluated the predictive effect of potential biomarkers on predicting pre-eclampsia. Maternal serum sFlt-1, ADAM-12, PP-13, and vitamin D were measured at the end of the study using commercially available kits in a randomly selected subgroup of women (approximately 236 women) and in all cases of pre-eclampsia (approximately 45 women). This same case cohort was analyzed for the following variables: placental volume (PV), placental and subplacental vascular distribution index (IV), flow index (FI), and blood flow index (VFI).

[0234] IV. Judgment criteria Primary endpoint: Pre-eclampsia requiring delivery before 34 weeks of gestation based on gestational age determined by the date of last menstrual period (DMD) or 11-13 week ultrasound (if the latter shows a difference of ≥5 days by the DMD method). Pre-eclampsia diagnosed according to the following criteria: 1) Gestational hypertension ≥140 systolic and / or ≥90 diastolic (twice within 4 hours), with the following condition: growth retardation <10 e This was combined with any of the following: percentile, thrombocytopenia <100, AST and / or ALT greater than twice the normal value, diastolic blood pressure ≥110 mmHg, and / or proteinuria (≥2+ on stick or greater than 300 mg / 24 hours).

[0235] Secondary endpoint: Childbirth <37 weeks (natural birth or PPROM before 37 weeks of pregnancy) Childbirth <34 weeks (natural birth or PPROM before 34 weeks of pregnancy)

[0236] Pre-eclampsia: Premature birth with preeclampsia <37 weeks Severe pre-eclampsia (having any of the following conditions: 1) systolic and diastolic blood pressure ≥160 mmHg and ≥110 mmHg after 4 hours of rest, 2) proteinuria ≥5 g / 24 hours or ≥3+ on the rod, 3) oliguria ≤400 mL / 24 hours, visual or brain impairment, epigastric pain, pulmonary edema or cyanosis, thrombocytopenia <100,000 mm3). Perinatal mortality (before delivery, up to 7 days after birth) Growth delay based on Canadian standards (<10 e Percentile) Severe syncope (<3) based on Canadian standards e Percentile) Birth weight <2500 grams Birth weight <1500 grams average birth weight

[0237] V. Data Analysis Plan Main analysis: At the end of the study, the calculation of the risks of early pre-eclampsia and pre-eclampsia was automatically performed by the FMF software using all the necessary collected data including uterine Doppler measurements. The risk calculation was automatically repeated for all eligible participants excluding uterine Doppler measurements.

[0238] The area under the curve, sensitivity, specificity, positive predictive value and negative predictive value of the two screening methods were reported and calculated using the ROC curve and different cut-off values.

[0239] Results: As can be seen from Figures 1 to 12, the data obtained from the PREDICTION study support the prognostic ability of sFlt-1 in identifying patients at risk of EO-PE and / or IUFD when analyzing samples obtained before 90 days of GA.

[0240] As can be seen from Figure 1, women with EO-PE (N = 10) had sFlt-1 levels below the median before 90 days of gestation (p < 0.01). On average, between 90 and 100 days of gestation, women with EO-PE (N = 24) had average sFlt-1 levels. Between 140 and 154 days of gestation, women with EO-PE (N = 4) had sFlt-1 above the median. From this study, we can conclude that the level of sFlt-1 abnormally decreases in early pregnancy (before 90 days of gestation) in women who develop early pre-eclampsia (before 34 weeks), increases progressively and becomes normal at the end of the first trimester (90 - 100 days), and then increases abnormally after 140 days of gestation.

[0241] However, sFlt-1 measurement does not provide a statistically significant correlation with EO-PE when determined from samples obtained throughout the first trimester (Figure 2). More notably, sFlt-1 measurement also does not provide a statistically significant correlation with EO-PE when determined from multiple samples obtained after 12 6 / 7 weeks of GA (Figures 3, 4).

[0242] Surprisingly, measurement of sFlt-1 within 12 weeks of gestation or within 90 days shows a significant correlation, particularly an inverse correlation, with EO-PE (Figures 5, 6). Therefore, determining sFlt-1 within 90 days from GA enables a reliable prognosis of EA-PE at an early stage.

[0243] The combined use of sFlt-1 and PlGF results in a statistical improvement in the prognosis of EO-PE when the sample is obtained early in pregnancy, for example, before the end of the 12th week of gestation (before 90 days GA). Notably, PlGF is typically effective in prognosticating EO-PE when measured after 90 days GA, while sFlt-1 does not seem to enable a reliable prognostic statement from a single measurement after 90 days GA (Figure 7). Surprisingly, both sFlt-1 and PlGF enable EO-PE prognosis when measured before the end of 12 weeks (within 90 days) GA. However, sFlt-1 seems to provide greater sensitivity with an equivalent specificity value, preferably a value exceeding 0.6 (Figure 8). Also surprisingly, the combined analysis of sFlt-1 and PlGF shows an unexpected multiplicative enhancement in EO-PE prognosis when measured before 90 days GA (Figure 9).

[0244] Also, through this study, it was found that the combined use of uterine artery Doppler measurements, preferably in combination with sFlt-1, PlGF, maternal age, and BMI, shows improved predictive power for EO-PE in the subjects compared to sFlt-1 or PlGF alone (Figure 10).

[0245] The combined use of sFlt-1 and PlGF also results in the prognosis of IUFD when the sample is obtained between 90 - 11 days GA (Figure 11) and shows a statistical improvement in the prognosis of IUFD when the sample is obtained before 90 days GA (Figure 12).

[0246] Furthermore, comparisons of datasets obtained using the FMF algorithm and sFlt-1 analysis described herein reveal that the two prognostic procedures are strongly correlated with each other. As can be seen from Figure 13, patients with high risk, as determined by the FMF algorithm, have significantly lower sFlt-1 levels before 90-day GA. Given that the FMF screening algorithm involves consideration of multiple maternal characteristics and medical history, including factors such as blood pressure, pregnancy-related plasma protein A and placental growth factor, crown-rump length, and uterine artery pulsation index, this finding represents a significant simplification in prognostic approaches that enable comparable risk assessment, thereby potentially avoiding a more complex FMF approach. Analysis of sFlt-1 90 days prior may, in fact, enable prediction of pregnant women undergoing a positive FMF test without requiring Doppler uterine artery assessment.

[0247] In conclusion, this study allowed us to conclude that in the majority of pregnant women who develop premature preeclampsia, sFlt-1 levels decrease before 90 days of gestation but then increase, becoming abnormally high in the second trimester of pregnancy in the same women. Therefore, sFlt-1 levels before 90 days of gestation, especially when combined with PlGF and / or uterine artery Doppler (40% detection rate for 10% FPR), can predict early-onset PE. Furthermore, we also observed that the combination of the two markers could predict approximately 35% of UFDIs with a 10% false-positive rate.

[0248] The importance of this information lies in the fact that early aspirin or similar therapy in the first stage is initiated in an attempt to address and potentially avoid EO-PE, making the treatment more effective. Therefore, the present invention enables an alternative and improved diagnostic approach to identify patients at risk of EO-PE by using biomarker analysis of samples obtained early in pregnancy, before 90 days GA, as well as subsequent initiation and guidance of treatment. Preferred embodiments of the present invention are as follows: [1] A method for prognosis, prediction, risk assessment and / or risk stratification of premature eclampsia in pregnant subjects, a. Determining the level of soluble fms-like tyrosine kinase-1 (sFlt-1) or its fragments in a sample isolated from the pregnant subject, b. The sample was isolated from the subject before the end of the 12th week of gestation. c. A method indicating that the level of sFlt-1 or a fragment thereof is likely to cause pre-eclampsia before the end of the 33rd week of gestation. [2] Furthermore, d. Determining the level of placental growth factor (PlGF) or its fragments in the sample isolated from the subject, e. The method according to [1], wherein the combination of the level of sFlt-1 or a fragment thereof and the level of PlGF or a fragment thereof indicates the likelihood of pre-eclampsia occurring before the end of the 33rd week of gestation. [3] The method according to [1] or [2] above, wherein the subject is in the 9th to 11th week of gestation. [4] The method according to [3], wherein the subject is in the 11th week of gestation. [5] Furthermore, a. Including determining or providing the maternal age, obesity index and / or uterine artery Doppler measurement values ​​of the subject, b. The method according to any one of claims [1] to [4], wherein the combination of the level of sFlt-1 or a fragment thereof, preferably in combination with the level of PlGF or a fragment thereof, with the maternal age, body mass index and / or uterine artery Doppler measurement of the subject, indicates pre-eclampsia occurring before the end of the 33rd week of gestation. [6] Furthermore, a. Including determining or providing the mean arterial pressure (MAP) level of the subject, b. The method according to any one of claims [1] to [5], wherein the combination of the level of sFlt-1 or a fragment thereof, preferably in combination with the level of the target MAP, indicates pre-eclampsia occurring before the end of the 33rd week of gestation. [7] a. Determining the level of sFlt-1 or its fragments in the sample isolated from the subject, and determining the level of PIGF or its fragments, b. Determining or providing the maternal age, body mass index (BMI), and uterine artery Doppler measurement values ​​of the subject, and optionally, mean arterial pressure (MAP), c. The method according to any one of the claims [1] to [6], wherein a combination of the level of sFlt-1 or a fragment thereof, the level of PlGF or a fragment thereof, and the maternal age, body mass index (BMI), and uterine artery Doppler measurement of the subject, and optionally, mean arterial pressure (MAP), indicates the likelihood of pre-eclampsia occurring before the end of the 33rd week of gestation. [8] a. Determining the level of sFlt-1 or its fragments in the sample isolated from the subject, and determining the level of PIGF or its fragments, b. Determining or providing the maternal age, body mass index (BMI), and mean arterial pressure (MAP) of the subject, and optionally, uterine artery Doppler measurements, The method according to any one of the claims [1] to [7], wherein the combination of the level of sFlt-1 or a fragment thereof, the level of PlGF or a fragment thereof, and the maternal age, body mass index (BMI), and mean arterial pressure (MAP) of the subject, and optionally, a uterine artery Doppler measurement, indicates the likelihood that pre-eclampsia will occur before the end of the 33rd week of gestation. [9] The method according to any one of the claims [1] to [8], wherein the level of sFlt-1 or its fragments determined in the sample is compared to a reference level, preferably the population mean and / or median for a healthy population, and a level of sFlt-1 or its fragments below the reference level indicates a high risk of pre-eclampsia.

[10] The method according to any one of the claims [2] to [8], wherein the level of PlGF or its fragments determined in the sample is compared to a reference level, preferably the population mean and / or median for a healthy population, and a level of PlGF or its fragments above the reference level indicates a high risk of pre-eclampsia.

[11] The method according to any one of the claims [1] to

[10] , wherein the combination of the level of sFlt-1 or a fragment thereof, preferably the level of sFlt-1 or a fragment thereof, the level of PlGF or a fragment thereof, and the maternal age, body mass index (BMI), and uterine artery Doppler measurement of the subject, and optionally, mean arterial pressure (MAP), indicates the early onset of pre-eclampsia occurring from the beginning of the 20th week of gestation and the end of the 33rd week of gestation.

[12] The method according to any one of the claims [1] to

[11] , wherein a combination of the level of sFlt-1 or a fragment thereof, preferably the level of sFlt-1 or a fragment thereof, the level of PlGF or a fragment thereof, and the maternal age, body mass index (BMI), and uterine artery Doppler measurement of the subject, and optionally mean arterial pressure (MAP), further indicates the subsequent occurrence of intrauterine fetal death (IUFD).

[13] The method according to any one of the above [1] to

[12] , wherein the maternal age is 18 to 34 or greater than 34.

[14] The method according to any one of the above [1] to

[13] , wherein the sample is a body fluid sample, such as a blood sample, such as a venous blood sample, a capillary blood sample, a serum sample, a plasma sample, a vaginal fluid sample, a saliva sample, or an amniotic fluid sample, preferably a blood, serum, or plasma sample.

[15] The method according to any one of the preceding paragraphs [1] to

[14] , wherein the level of sFlt-1 or a fragment thereof in the subject, and optionally, the level of PlGF or a fragment thereof, maternal age, body mass index (BMI), uterine artery Doppler measurement, and / or mean arterial pressure (MAP), indicates that the treatment of the subject is initiated or modified to reduce the risk of developing pre-eclampsia, delay the onset of pre-eclampsia, and / or reduce the severity of pre-eclampsia, and / or protect the function of organs such as the kidneys and / or liver, for example, by balancing the angiogenesis / anti-angiogenesis process in placental development, lowering blood pressure.

[16] The method according to any one of the claims [1] to

[15] , wherein the treatment is selected from the group consisting of one or more diuretics, beta-blockers, ace inhibitors, angiotensin II receptor blockers, calcium channel blockers, alpha-blockers, methyldopa, central agonists, and vasodilators, VEGF, PLGF, statins, arginine vasopressin receptor antagonists, L-arginine, citrulline, arginase (nor-NOHA) inhibitors, iron chelators (deferoxamine), heparin, magnesium sulfate, diazepam, phenytoin, vitamin D, calcium, molecular selenium inhibitors, in vitro extraction (e.g., apheresis), lifestyle recommendations, outpatient monitoring, and increasing the frequency of maternal and fetal monitoring.

[17] The method according to

[14] , wherein the treatment comprises the administration of acetylsalicylic acid.

[18] The method according to any one of the above [1] to

[17] , wherein the subject is heiferous.

[19] The method according to any one of the above [1] to

[18] , wherein the subject has had one or more previous pregnancies.

[20] The method according to any one of the above [1] to

[19] , wherein the subject has a multiple pregnancy.

[21] The method according to any one of the above items [1] to

[20] , wherein the subject is suspected of being pregnant with a fetus having a chromosomal abnormality.

[22] The method according to any one of the above [1] to

[21] , wherein the subject has one or more risk factors selected from the group consisting of hypothyroidism, hyperthyroidism, BMI greater than 24, primipregnancy, history of pre-eclampsia, ethnicity with risk disorders, multiple pregnancy, migraine, lupus, blood coagulation disorders, e.g., hypercoagulation, inflammatory disease, cardiac predisposition, diabetes mellitus, chronic kidney disease, and chronic hypertension.

[23] Further comprising determining the level of at least one additional biomarker or fragment thereof in a sample from the patient, wherein the at least one additional biomarker is βhCG, copeptin, vasopressin, troponin, BNP, ANP, CRP, thrombocytocyte / leukocyte, IL6, IL11, MR-proADM, VEGF, PAPP-A, PIGF, endoglin, pro-Epil, PP-13, ADAM-12, vitamin D, inhibin-a, activin-a, pentraxin-3, p-selectin, free fetal hemoglobin, α-1-microglobulin, unconjugated estriol, α-fetoprotein, GDF15, neurophysin II, LNPEP, ESM1, HGF, picachulin, hemopexin, pp13, uE3, CT-proET1, ADAM12, sTNFαR1, RBP4, I The method according to any one of claims [1] to

[22] , wherein the levels of the at least one additional biomarker and the levels of sFlt-1 or a fragment thereof indicate pre-eclampsia prematurely before the end of the 33rd week of gestation.

[24] A kit for carrying out the method described in any one of the above items [1] to

[23] , -A detection reagent for determining the level of sFlt-1 or its fragments in a sample from a target, and for determining the level of PIGF or its fragments, -Computer executable code, i. The determined levels of i.sFlt-1 or its fragments and the determined levels of PlGF or its fragments are preferably compared to one or more reference levels corresponding to the population mean and / or median for a healthy population. ii. A kit comprising a computer-readable medium and / or computer software in the form of computer-executable code, configured to compare the maternal age, body mass index, MAP and / or uterine artery Doppler measurement values ​​of the subject with one or more reference levels, preferably corresponding to the population mean and / or median for a healthy population.

Claims

1. A method for prognosis, prediction, risk assessment, and / or risk stratification of premature eclampsia in pregnant subjects, a. This includes determining the level of soluble fms-like tyrosine kinase-1 (sFlt-1) or its fragments in a sample isolated from the pregnant subject, b. The sample was isolated from the subject before the end of the 12th week of gestation. c. A method indicating that the level of sFlt-1 or a fragment thereof is likely to cause pre-eclampsia before the end of the 33rd week of gestation.

2. Furthermore, a. This includes determining the level of placental growth factor (PLGF) or its fragments in the sample isolated from the subject, b. The method according to claim 1, wherein the combination of the level of sFlt-1 or a fragment thereof and the level of PlGF or a fragment thereof indicates the likelihood of pre-eclampsia occurring before the end of the 33rd week of gestation.

3. The method according to claim 1, wherein the subject is in the 9th to 11th week of gestation.

4. The method according to claim 3, wherein the subject is in the 11th week of gestation.

5. Furthermore, a. Including determining or providing the maternal age, obesity index and / or uterine artery Doppler measurement values ​​of the subject, b. The method according to claim 1, wherein the combination of the level of sFlt-1 or a fragment thereof with the maternal age, body mass index and / or uterine artery Doppler measurement of the subject indicates pre-eclampsia occurring before the end of the 33rd week of gestation.

6. Furthermore, a. Including determining or providing the mean arterial pressure (MAP) level of the subject, b. The method according to claim 1, wherein the combination of the level of sFlt-1 or a fragment thereof with the level of the MAP of the subject indicates pre-eclampsia occurring before the end of the 33rd week of gestation.

7. a. Determining the level of sFlt-1 or its fragments in the sample isolated from the subject, and determining the level of PlGF or its fragments, b. The method includes determining or providing the maternal age, body mass index (BMI), and uterine artery Doppler measurement values ​​of the subject, and optionally, mean arterial pressure (MAP), c. The method according to claim 1, wherein a combination of the level of sFlt-1 or a fragment thereof, the level of PlGF or a fragment thereof, and the maternal age, body mass index (BMI), and uterine artery Doppler measurement of the subject, and optionally, mean arterial pressure (MAP), indicates the likelihood of pre-eclampsia occurring before the end of the 33rd week of gestation.

8. a. Determining the level of sFlt-1 or its fragments in the sample isolated from the subject, and determining the level of PlGF or its fragments, b. The method includes determining or providing the maternal age, body mass index (BMI), and mean arterial pressure (MAP) of the subject, and optionally, uterine artery Doppler measurements. c. The method according to claim 1, wherein a combination of the level of sFlt-1 or a fragment thereof, the level of PlGF or a fragment thereof, the maternal age, body mass index (BMI), and mean arterial pressure (MAP) of the subject, and optionally, a uterine artery Doppler measurement, indicates the likelihood of pre-eclampsia occurring before the end of the 33rd week of gestation.

9. The method according to claim 1, wherein the level of sFlt-1 or its fragments determined in the sample is compared to a reference level corresponding to the population mean and / or median for a healthy population, and a level of sFlt-1 or its fragments below the reference level indicates a high risk of pre-eclampsia.

10. The method according to claim 2, wherein the level of PlGF or its fragments determined in the sample is compared to a reference level corresponding to the population mean and / or median for a healthy population, and a level of PlGF or its fragments exceeding the reference level indicates a high risk of pre-eclampsia.

11. The method according to claim 1, wherein the level of sFlt-1 or a fragment thereof indicates the early onset of pre-eclampsia occurring from the beginning of the 20th week of gestation and the end of the 33rd week of gestation.

12. The method according to claim 1, wherein the level of sFlt-1 or a fragment thereof further indicates the subsequent occurrence of intrauterine fetal death (IUFD).

13. The method according to claim 1, wherein the maternal age of the subject is 18 to 34, or greater than 34.

14. The method according to claim 1, wherein the sample is a body fluid sample selected from the group consisting of blood samples, venous blood samples, capillary blood samples, serum samples, plasma samples, vaginal fluid samples, saliva samples, and amniotic fluid samples.

15. The method according to claim 1, wherein the level of sFlt-1 or a fragment thereof in the subject, and optionally, the level of PlGF or a fragment thereof, maternal age, body mass index (BMI), uterine artery Doppler measurement, and / or mean arterial pressure (MAP), are used to initiate or modify treatment of the subject in order to reduce the risk of developing pre-eclampsia, delay the onset of pre-eclampsia, and / or reduce the severity of pre-eclampsia by lowering blood pressure and / or protecting organ function.

16. The method according to claim 15, wherein the treatment is selected from the group consisting of one or more diuretics, beta-blockers, ACE inhibitors, angiotensin II receptor blockers, calcium channel blockers, alpha-blockers, methyldopa, central agonists, and vasodilators, VEGF, PLGF, statins, arginine vasopressin receptor antagonists, L-arginine, citrulline, arginase inhibitors, iron chelators, heparin, magnesium sulfate, diazepam, phenytoin, vitamin D, calcium, molecular selenium inhibitors, in vitro extraction, lifestyle recommendations, outpatient monitoring, increased frequency of maternal and fetal monitoring, and low-dose acetylsalicylic acid.

17. The method according to claim 15, wherein the treatment comprises the administration of acetylsalicylic acid.

18. a. The subject is nulliparous, b. The subject has had one or more previous pregnancies, c. The subject has a multiple pregnancy, and / or d. The subject is suspected of being pregnant with a fetus that has a chromosomal abnormality. The method according to claim 1.

19. The method according to claim 1, wherein the subject has one or more risk factors selected from the group consisting of hypothyroidism, hyperthyroidism, BMI greater than 24, primiparous pregnancy, history of pre-eclampsia, ethnicity with risk disorders, multiple pregnancy, migraine, lupus, blood coagulation disorders, inflammatory diseases, cardiac predisposition, diabetes mellitus, chronic kidney disease, and chronic hypertension.

20. The method according to claim 1, further comprising determining the level of at least one additional biomarker or fragment thereof in a sample from the subject, wherein the at least one additional biomarker is selected from the group consisting of βhCG, PAPP-A, PlGF, uE3, AFP, uterine artery Doppler (UtA-Pi), MAP, blood pressure, and smoking, and the level of the at least one additional biomarker and the level of sFlt-1 or fragment thereof indicate pre-eclampsia occurring before the end of the 33rd week of gestation.

21. A kit for carrying out the method described in any one of claims 1 to 20, - A detection reagent for determining the level of sFlt-1 or its fragments in a sample from the target, and a detection reagent for determining the level of PlGF or its fragments, - Computer-readable media and / or computer software in the form of computer executable code, i. Comparing the determined levels of sFlt-1 or its fragments and the determined levels of PlGF or its fragments to one or more reference levels corresponding to the population mean and / or median for a healthy population, ii. Comparing the maternal age, body mass index, MAP, and / or uterine artery Doppler measurements of the subject with one or more reference levels corresponding to the population mean and / or median for a healthy population, Computer-readable media and / or computer software configured to perform the following: A kit that includes this.

Images