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(sFlt-1) and placental growth factors (PlGFs).3 In contrast, lateonset preeclampsia, defined as the onset after 34 weeks of gestation, is not necessarily accompanied by placental dysfunction4
but angiogenic and antiangiogenic factors are also dysregulated,
though to a less dramatic extent.5
We and others have previously shown that the sFlt-1/PlGF
ratio is elevated in patients with preeclampsia.610 The automated measurement of the sFlt-1/PlGF ratio detects early-onset
preeclampsia with a sensitivity of 89% and a specificity of 97%
when the single, gestation-wide cutoff of 85 is used.8 Recently,
Rana et al9 have shown that in patients with signs and symptoms
for the disease, an sFlt-1/PlGF ratio 85 predicts the occurrence
of preeclampsia-related adverse maternal and fetal outcomes,
Received June 15, 2013; first decision July 7, 2013; revision accepted October 1, 2013.
From the Department of Obstetrics, Campus Virchow-Clinic, Charit University Medicine Berlin, Berlin, Germany (S.V., K.S.); Fetal Medicine Unit,
Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain (I.H., A.G.);
Department of Obstetrics and Gynecology, University of Basel, Basel, Switzerland (O.L.); Department of Obstetrics and Gynecology, University of Jena,
Jena, Germany (D.S.); Department of Obstetrics and Gynecology, University of Vienna Medical School, Vienna, Austria (H.Z.); Department of Obstetrics
and Gynecology, Charles University, Prague, Czech Republic (P.C.); Department of Obstetrics and Gynecology, University Hospital Sant Joan de Du,
Espluges, Spain (J.S.); Department of Obstetrics and Gynecology, University of Freiburg, Freiburg, Germany (F.M.-E.); Roche Diagnostics, Clinical
Operations Professional Diagnostics, Penzberg, Germany (B.D.); and Department of Obstetrics, University Hospital Leipzig, Leipzig, Germany (H.S.).
The online-only Data Supplement is available with this article at http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYPERTENSIONAHA.
113.01787/-/DC1.
Correspondence to Stefan Verlohren, Department of Obstetrics, Charit University Medicine Berlin, Charitplatz 1, D-10117 Berlin, Germany. E-mail
stefan.verlohren@charite.de
2013 American Heart Association, Inc.
Hypertension is available at http://hyper.ahajournals.org
DOI: 10.1161/HYPERTENSIONAHA.113.01787
Methods
Study Population
Singleton pregnancies were enrolled at 9 European perinatal care
centers. An identical study protocol and data collection form was
used at each center. The local ethics committees and institutional
review boards approved the study, and all subjects gave their written
informed consent before participation.
Preeclampsia was defined according to the National High Blood
Pressure Education Program Working Group on High Blood Pressure in
Pregnancy.11 The syndrome of hemolysis, elevated liver enzymes, and
low platelets (HELLP syndrome), superimposed preeclampsia, and intrauterine growth restriction were defined as previously published.8 In
this study, patients with any form of preeclampsia or HELLP were combined in the preeclampsia/HELLP group (preeclampsia/HELLP) for
analysis. A pregnancy outcome was defined as normal if the mother was
not diagnosed with any form of preeclampsia/HELLP and the infant
was not diagnosed with intrauterine growth restriction. Investigators
were blinded to sFlt-1 and PlGF levels which prevented an influence of
this information on decision making and defining time point of delivery.
A total of 1149 individuals were enrolled in the study: 915 singleton
pregnancies with normal pregnancy outcome and 234 singleton pregnancies with preeclampsia outcome. At least 100 preeclampsia/HELLP
cases for each early and late gestational phase were determined by
study protocol as target numbers for the nested casecontrol population. Recruitment was performed in a prospective manner until these
targets were obtained with the consequence of enrolling 1149 patients.
Two subsets of this data collective were built (Figure S1 in the onlineonly Data Supplement). For analysis of reference ranges, maximum 1
visit from each subject per gestational age window was included in case
of follow-up visits in the control group. Therefore, this subset contains
1685 control visits from 877 subjects. An additional 38 control subjects
either contributed samples only before week 10 or were not normotensive and were therefore excluded from the reference range analysis. For
the determination of gestational agedependent reference values, we
analyzed 7 gestational age windows: window 1: 10+0 to 14+6 weeks
of gestation; window 2: 15+0 to 19+6 weeks of gestation; window 3:
20+0 to 23+6 weeks of gestation; window 4: 24+0 to 28+6 weeks of
gestation; window 5: 29+0 to 33+6 weeks of gestation; window 6: 34+0
to 36+6 weeks of gestation; and window 7: 37+0 weeks of gestation to
delivery. All gestational age windows comprise 5 weeks except window
3 (2023+6 weeks of gestation) and window 6 (34+036+6 weeks of
gestation), acknowledging clinical thresholds at 24+0 (viability), 34+0
(early/late preeclampsia), and 37+0 weeks of gestation (preterm birth).
For receiver operating characteristics (ROC) curves and analysis of the
cutoff, a total of 234 subjects with a preeclampsia/HELLP outcome were
matched to 468 subjects with uneventful pregnancy outcomes. Only visits
from subjects with a gestational age of 20+0 weeks were included. In
patients with preeclampsia/HELLP, only the first visit after confirmation
Statistics
Basic statistics (mean, median, SD, quartiles, and range) were performed
for sFlt-1, PlGF, and the sFlt-1/PlGF ratio. To compare clinical subgroups, descriptive statistics (medianinterquartil ranges) were generated. Gestational agedependent reference values were determined per
time window as quantiles. For the statistical comparison of marker levels
in the respective clinical groups, data were transformed as appropriate
and either parametric (ANOVA, t test) or nonparametric (Wilcoxon/
KruskalWallis) tests were applied. All P values are 2-tailed. Statistical
significance was assigned when a P value was <0.05. All statistical analyses were performed using SAS. ROC analysis was used for the evaluation
of the area under curve and the sensitivity and specificity as a function of
cutoff for markers sFlt-1, PlGF, and sFlt-1/PlGF ratio. Positive and negative likelihood ratios (LR+/LR) were calculated. Gerhard plots were
generated to find optimized cutoff values for the single markers and the
ratio. A generalized linear regression model with a -distributed response
regarding the positively skewed, continuous distribution was applied to
test for confounding effects of body mass index and maternal age.
Results
Demographic and Clinical Baseline Characteristics
No significant differences were found in age, height, and
weight between patients with early- or late-onset preeclampsia and their gestational agematched controls. As expected,
patients with preeclampsia had a significantly earlier date of
delivery, higher systolic and diastolic blood pressure, higher
body mass index, and lower neonatal birth weight (P<0.05 or
P<0.001 where appropriate, Table S1).
348HypertensionFebruary 2014
Table 1. Norm Values for the sFlt-1/PlGF Ratio, sFlt-1, and PlGF
Completed Weeks of Gestation
Centiles
1014
1519
2023
2428
2933
3436
37
sFlt-1/PlGF
ratio
Q 2.5
7.39
3.18
1.29
0.88
0.84
0.90
1.67
Q 5
9.27
3.51
1.82
0.95
0.94
1.23
2.18
Q 10
11.6
4.67
2.22
1.22
1.22
2.15
3.81
Median
24.8
10.5
4.92
3.06
3.75
9.03
19.6
Q 90
46.6
20.5
11.0
7.49
16.1
43.4
85.7
Q 95
54.6
25.7
14.6
10.0
33.9
66.4
112
Q 97.5
65.0
28.7
17.5
14.9
62.8
89.9
134
sFlt-1
Q 2.5
586
532
477
520
695
912
1262
Q 5
652
708
572
618
773
992
1533
Q 10
776
844
718
722
967
1220
1899
Median
1328
1355
1299
1355
1742
2552
3485
Q 90
2174
2453
2605
2557
3650
5620
7901
Q 95
2501
2807
2997
3205
5165
7363
9184
Q 97.5
2707
3382
3592
3912
5985
8214
11471
PlGF
Q 2.5
26.8
57.2
106
145
91
68.0
48.9
Q 5
28.8
66.2
119
169
114
78.0
54.4
68.6
Q 10
31.3
80.9
143
200
139
98.2
Median
52.6
135
264
465
471
284
191
Q 90
100
251
500
921
1073
831
620
Q 95
122
289
605
1117
1297
984
862
Q 97.5
136
322
694
1668
1567
1378
1006
246
157
217
346
319
224
176
Serum values of the sFlt-1/PlGF ratio, sFlt-1, and PlGF in patients with normal pregnancy outcome. The median as well as
the centiles (Q) 2.5, 5, 10 and 90, 95, and 97.5 in the 7 gestational age windows sorted by completed weeks of gestation are
displayed. n indicates number of patients; PlGF, placental growth factor; and sFlt-1, soluble fms-like tyrosine kinase-1.
25th75th centile, 92.5427) versus 7.78 (n=468; 25th75th centile, 3.2923.9; P<0.001) in women with uneventful pregnancy
outcome (Figure1A, left). In patients with superimposed preeclampsia, the median sFlt-1/PlGF ratio was 75.4 (n=14; 25th
75th centile, 18.0141); in patients with isolated HELLP, 420
(n=15; 25th75th centile, 192814); in patients with preeclampsia not being severe or complicated by HELLP syndrome, 116
(n=99; 25th75th centile, 51.7202); and in patients with severe
preeclampsia, 350 (n=106; 25th75th centile, 170574; P<0.001
KruskalWallis for subgroup comparison; Figure1A, right).
The median sFlt-1/PlGF ratio in patients with early-onset preeclampsia was 424 (n=100; 25th75th centile, 186717) versus 129
(n=134; 25th75th centile, 59207; P<0.001) in late-onset cases.
Patients with uncomplicated pregnancies 33+6 weeks of gestation
(n=200) had a median sFlt-1/PlGF ratio of 3.68 (25th75th centile,
2.037.50) versus 16.2 (25th75th centile, 6.5037.0; P<0.001) in
control patients 34+0 weeks of gestation (n=268; Figure1B).
was established. For the early gestational phase, the rationale for
choosing the cutoffs was to reach a 95% sensitivity (at the low
cutoff) and 95% specificity (at the high cutoff; Figure3). In this
group, a cutoff of 33 resulted in a sensitivity of 95% and a specificity of 94%, corresponding to an LR of 0.05 (95% CI, 0.020.13)
and an LR+ of 15.8 (95% CI, 9.1327.5). In total numbers, 95
of 100 patients were correctly classified as having preeclampsia, whereas 188 of 200 were correctly diagnosed as not having
preeclampsia. However, in the same early phase, a cutoff of 85
resulted in a sensitivity of 88% and a specificity of 99.5% and
yielded an LR+ of 176 (95% CI, 24.91245) and an LR of 0.12
(95% CI, 0.070.21). All 200 patients bar one were correctly classified as healthy, using the cutoff of 85. In combining the cutoffs
33/85, 95 of 100 preeclamptic patients were correctly classified
and only 5 were incorrectly diagnosed as not being preeclamptic,
whereas only 1 in 100 healthy pregnancies was incorrectly classified as having preeclampsia (Tables2 and 3).
For the late gestational phase, the cutoffs were chosen to
reach a minimum of 95% specificity for the early cases of
late-onset preeclampsia/HELLP (34< 37 weeks of gestation). Here, a cutoff of 33 resulted in a sensitivity of 89.6%, a
Discussion
The aim of the study was to provide reference ranges and cutoffs for the clinical use of the sFlt-1/PlGF ratio as an aid in diagnosis of preeclampsia. Previous work from our group as well
as from others has consistently shown that the automated measurement of sFlt-1, PlGF and the calculation of the sFlt-1/PlGF
ratio is a reliable tool for the diagnosis of preeclampsia.8,10,1315
We reported earlier a cutoff of 85 for the sFlt-1/PlGF ratio
as an aid in diagnosis of preeclampsia regardless of the gestational week tested. This preliminary cutoff was based on a case
control cohort of 71 patients with preeclampsia and 280 control
patients.8 In the preliminary analysis, a cutoff of 85 resulted in
a sensitivity of 82% and a specificity of 95% for diagnosing
350HypertensionFebruary 2014
Figure 2. Receiver operating characteristics curves for the discrimination of healthy and preeclamptic pregnancies by means of the
soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio (left), sFlt-1 (middle), and PlGF (right). The black line
represents all patients, the green line represents patients from the early gestational phase, and the blue line represents patients from the
late gestational phase. On the x axis, false positive/1specificity, and on the y axis, true positive/sensitivity are expressed.
Table 2. Sensitivities and Specificities With 95% CIs for the Whole as Well as for Early and Late Gestational Phases
Whole Gestational Phase (Wk 20+0Delivery)
Sens/Spec
Absolute
Relative
95% CI
Cutoff 85
Absolute
Relative
95% CI
Absolute
Cutoff 33
Relative
95% CI
Cutoff 33
Sens
177/234
75.6%
70.6100
Sens
95/100
95.0%
89.8100
Sens
120/134
89.6%
84.2100
Spec
447/468
95.5%
93.6100
Spec
188/200
94.0%
90.5100
Spec
196/268
73.1%
68.3100
Cutoff 85
Cutoff 110
Sens
88/100
88.0%
81.3100
Sens
78/134
58.2%
50.7100
Spec
199/200
99.5%
97.7100
Spec
256/268
95.5%
92.9100
CI indicates confidence interval; Sens, sensitivities; and Spec, specificities. Bold values indicate the outer borders of the cut-off.
Estimate
95% CI
LR
Cutoff 33
LR+
LR
15.8
0.05
9.1327.5
LR+
0.020.13
LR
Cutoff 85
LR+
LR
176
0.12
Estimate
95% CI
Cutoff 33
3.33
2.714.10
0.14
0.090.24
Cutoff 110
24.91245
LR+
13
7.3423.0
0.070.21
LR
0.44
0.360.54
CI indicates confidence interval; LR, likelihood ratio. Bold values indicate the
outer borders of the cut-off.
Limitations
Our study has limitations. We have performed a casecontrol
study with a 2:1 matching in the ROC group. Because of the
design, with a constructed incidence of preeclampsia of 33.3%,
we were not able to calculate positive or negative predictive values. Individual cutoffs could be established only for 2 gestational
phases. The data set is too small to establish cutoffs for shorter
time intervals, which resulted in a sudden change of cutoffs at
34+0 weeks of gestation. For the late gestational age group,
there is a significant proportion of patients inside the equivocal
zone. Almost 30% of the patients with preeclampsia/HELLP
and almost 25% of the controls need to be retested. For these
patients, data are lacking on when and how often they have to be
retested. We evaluated singleton pregnancies in this study, therefore our results only apply to this group of patients. It is known,
however, that multifetal gestations exhibit different patterns of
angiogenic factor serum levels with healthy twin pregnancies
exhibiting a 3-fold increase in the sFlt-1/PlGF ratio as compared
Clinical Value
The clinical presentation of preeclampsia is diverse, and the
diagnosis of atypical cases of preeclampsia is a daily challenge
to the practicing obstetrician.17 Current definitions and guidelines rely solely on the measurement of blood pressure and proteinuria to diagnose the disease.2,18 However, the measurement
of blood pressure and proteinuria has low predictive accuracy
of adverse maternal and fetal outcomes. Recently, Rana et al9
have shown that in women with suspected preeclampsia, the
sFlt-1/PlGF ratio helps to identify those who will develop a preeclampsia-related pregnancy complication. In addition to the
gold standard of preeclampsia diagnostics, the measurement of
blood pressure and proteinuria, the sFlt-1/PlGF ratio is able to
improve prediction of adverse preeclampsia-related outcomes.9
Various groups have shown that 1 single cutoff at 85 is not
optimal for diagnosing preeclampsia or other hypertensive pregnancy disorders in all clinical settings.14,19,20 The new gestational
phasespecific 2 cutoffs allow maximized accuracy of diagnosis. A more precise diagnosis and gestational phasedependent
analysis might have future therapeutic consequences. Recently,
a pilot study has shown a possible therapy for women with
early-onset preeclampsia. Preeclamptic women who underwent
sFlt-1 apheresis had longer remaining pregnancy duration.21
Removal of sFlt-1 resulted in amelioration of kidney function
and prolongation of pregnancy. Therefore, the sFlt-1/PlGF ratio
might have importance as a parameter to monitor disease severity and hence therapeutic progress.
Figure 3. Gerhard plots displaying the decision limits for ruling in and out as a basis for finding cutoffs and equivocal zone. Values were
taken from receiver operating characteristics analysis: the light blue line represents the sensitivity, and the dark blue line represents the
specificity. Left, The localization of the present cutoff of 85 in the Gerhard plot for the whole gestational phase. Middle, The gestational
phasespecific cutoffs for the early phase. Right, The gestational phasespecific cutoffs for the late phase. The color fills are chosen to
represent interpretations of the test result: below the (lower) cutoff, green indicates low risk; above the (upper) cutoff, red stands for high
risk; inside the equivocal zone, yellow indicates intermediate risk.
352HypertensionFebruary 2014
Perspectives
The use of an equivocal zone and focus on the outer borders
of this zone to rule in or rule out patients with preeclampsia
enhances the diagnostic accuracy of the sFlt-1/PlGF ratio with
the potential to reduce maternal and fetal morbidity and mortality. Below 34 weeks of gestation, an sFlt-1/PlGF ratio of 33 is
associated with an LR of 0.05, whereas values 85 have a likelihood of a positive test of 176. For late-onset preeclampsia, the
LR at the cutoff 33 is 0.14, the LR+ at 110 is 13. Looking at
the clinical feasibility, a simple diagnostic algorithm is desirable
for the user. However, the establishment of differential cutoffs for
different gestational phases instead of using 1 single cutoff value
better reflects the pathophysiology of the disease. In our opinion,
this approach of gestational phasespecific cutoff values provides
a reasonable balance/compromise between both needs.
Sources of Funding
P. Calda has received funding by grant RVO-VFN64165/2012. The
study was supported by Roche Diagnostics, Germany.
Disclosures
B. Denk is employed by Roche Diagnostics, Penzberg, Germany. H.
Stepan has received consultancy payments from Roche regarding advice on clinical trial design. S. Verlohren has received consultancy
payments from Roche regarding advice on data analysis and publication. S. Verlohren and H. Stepan received lecture fees from Roche.
The other authors report no conflicts.
References
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What Is Relevant?
Summary
The use of multiple cutoffs better reflects the pathophysiological
and clinical difference of early and late preeclampsia and might
thus improve clinical diagnostics and management.
Up to now only 1 cutoff for the clinical use of the soluble fms-like tyrosine
kinase-1/placental growth factor ratio as an aid in diagnosis has been
evaluated.
Online supplement
HYPE201301787: New gestational phase specific cut-off values for the
use of the sFlt-1/PlGF-ratio as a diagnostic test for preeclampsia
Supplementary Methods:
Patients:
Briefly, hypertension was defined as the repeated measurement of systolic
140 mmHg (Korotkoff I) and diastolic 90 mmHg (Korotkoff V) blood
pressure. Proteinuria was defined as the excretion of 300 mg protein per day
in the 24 hour (h) urine collection or a repeated dipstick of 1+.
PE was defined as severe in contrast to mild, when hypertension 160/110
mmHg, proteinuria 5g/24h or the occurrence of organ failure (kidney, lung) or
neurologic symptoms were observed.
Inclusion criteria for the reference range cohort were the presence of informed
consent, maternal age 16 years, and a normal pregnancy outcome. A
normal pregnancy outcome refers to the mother not diagnosed with any form
of PE and the infant not diagnosed with intrauterine growth retardation
(IUGR). The exclusion criteria comprise the diagnoses of PE, HELLP
syndrome, IUGR, and all those for the PE group as stated below.
Samples
Maternal blood was collected by venipuncture in tubes without anticoagulant.
After clotting, the samples were centrifuged with 2000g and serum was
pipetted, and stored at 80C until testing. The sFlt-1 and PIGF
concentrations of each sample were determined in parallel.
Statistics
Gestational age-dependent reference values were determined per time
window as quantiles according to the respective protocols by International
Federation of Clinical Chemistry and Laboratory Medicine (IFCC) and Clinical
and Laboratory Standards Institute (CLSI),Smooth curves for gestational agedependent quantiles were determined using a robust quantile regression
method.
Table S1
Patient Characteristics
Age [y] median (IQR)
Height [cm] median (IQR)
Weight [kg] median (IQR)
BMI [kg/m^2] median (IQR)
Birth Weight [g] median (IQR)
Gestational Week of Delivery median
(IQR)
Max. diastolic BP [mmHg] median
(IQR)
Max. systolic BP [mmHg] median
(IQR)
Smoking: Current [N (%)]
Smoking: Past [N (%)]
Smoking: Never [N (%)]
Smoking: Unknown / NA [N (%)]
Race: White / Caucasian [N (%)]
Race: Black / African American [N (%)]
Race: Other [N (%)]
Race: Unknown / NA [N (%)]
Family History of PE: Yes [N (%)]
Family History of PE: No [N (%)]
Family History of PE: Unknown / NA [N
(%)]
N
PE/HELLP &
20+0-33+6
32.0 (28.0 - 35.0)
164 (160 - 170)
68.0 (56.0 - 81.0)
24.2 (21.5 - 29.9)*
1270 (861 1670)**
controls &
20+0-33+6
31.0 (27.0 - 35.0)
165 (160 - 169)
63.0 (57.0 - 75.0)
23.0 (20.6 - 27.9)
3125 (2779 3490)
PE/HELLP
& >34+0
30.5 (25.0 - 35.0)
165 (160 - 169)
66.5 (60.0 - 77.2)
24.5 (21.6 - 29.0)*
2800 (2200 3291)**
controls &
>34+0
31.0 (27.0 - 34.0)
165 (161 - 170)
64.0 (56.0 - 76.8)
23.5 (20.7 - 27.1)
10 (10%)
100
31 (15.5%)
200
22 (16.4%)
134
31 (11.6%)
268
Legend:
Baseline Characteristics: PE/HELLP patients 20+0 33+6 wks and 34+0 wks were compared to gestational age matched controls
(* p<0.05). Data is expressed in median and interquartile range (IQR). BMI = body mass index, BP = blood pressure, NA = not
applicable. IQR (interquartilrange): 25. percentile 75. Percentile, * p<0.05 vs. gestational phase matched controls, **p<0.001
vs. gestational phase matched controls
Figure S1
Figure
1
1149
(2403)
Singleton
pregnancies
915
(2095)
normal
pregnancy
outcome
234
(308)
PE/HELLP
outcome
200
early
phase
100
early
onset
268
late
phase
134
late
onset
Case-Control
Study
1.
visit
with
diagnosis
Case-Control
Study
Reference
Range
Study
468
1
visit
per
patient
matched
for
gest.
wk
38
not
normotensive
gest.
wk
10
877
(1685)
normotensive,
gest.
wk
10
multiple
visits
allowed
but
max.
1
visit
per
window
Legend:
Study Design: A total of 1149 patients yielding 2403 visits were analyzed in two separate study collectives. For the establishment of
reference ranges 915 singleton pregnancies with normal pregnancy outcome yielding 2095 visits were analyzed. After exclusion of
38 patients due to not being normotensive or yielding samples before wk 10, a total of 877 patients yielding 1685 visits remained.
Analysis was undertaken in seven gestational age windows (gest age window): Window 1: 10+0 - 14+6 week of gestation (wks),
window 2: 15+0 - 19+6 wks, window 3: 20+0 - 23+6 wks, window 4: 24+0 - 28+6 wks, window 5: 29+0 - 33+6 wks, window 6: 34+0
- 36+6 wks and window 7: 37+0 wks delivery. At most one visit from each subject per gestational age window was included in
case of follow-up visits in the control group.
For receiver operating characteristics curves (ROC) and analysis of the cut-off, only visits with a subjects' gestational age of at least
20 weeks were included. A total of 234 subjects with a PE/HELLP-outcome was matched to 468 subjects with uneventful
pregnancy outcome. Legend: early phase / onset: 20+0 33+6 wks; late phase / onset: >34+0 wks.
Figure S2 a
S8 6
Figure S2 b
Figure S2 c
Legend:
Scatter plots of maternal serum concentrations of sFlt-1 (a), PlGF (b) and calculated sFlt-1/PlGF-ratio (c) of uncomplicated
pregnancies (controls). The dots represent individual serum values, the smooth curves represent the median, 2.5 / 5 / 10 as well as
90 / 95 / 97.5 centile of the serum values of sFlt-1, PlGF and the sFlt-1/PlGF-ratio.
New Gestational PhaseSpecific Cutoff Values for the Use of the Soluble fms-Like
Tyrosine Kinase-1/Placental Growth Factor Ratio as a Diagnostic Test for Preeclampsia
Stefan Verlohren, Ignacio Herraiz, Olav Lapaire, Dietmar Schlembach, Harald Zeisler, Pavel
Calda, Joan Sabria, Filiz Markfeld-Erol, Alberto Galindo, Katharina Schoofs, Barbara Denk and
Holger Stepan
Hypertension. 2014;63:346-352; originally published online October 28, 2013;
doi: 10.1161/HYPERTENSIONAHA.113.01787
Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2013 American Heart Association, Inc. All rights reserved.
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