Background PAPP-A is a biochemical marker in first trimester screening undertaken at 11–13 weeks gestation. Studies have shown that low levels of it (<0.4 MoM) are descriptive of poor early placentation and can be an independent risk factor of complications associated with adverse obstetric outcomes.

Objective Review existing management and pregnancy outcome of women with low PAPP-A levels and formulate guidelines to establish uniform standard practice for better outcomes.

Method Following parameters were retrospectively analysed from case notes from January to December 2011:

Maternal Age Parity Miscarriage PAPP-A levels Aspirin Uterine artery Doppler Growth scan

Hypertension Delivery time Stillbirth APGAR SCBU admission

Results 81 identified with low PAPP-A

90% received counselling

46% commenced on low dose aspirin

88% had uterine artery doppler

75% had growth scans

66% had no growth restriction

66% had further dopplers

38% received steroids

64% had no adverse outcomes

60% of babies born had weight greater than 3kg

25% had SCBU admission

36% had adverse outcomes

Conclusion Low PAPP-A levels have limited value as a one-time single marker test and is poorly sensitive. Likelihood of an adverse outcome increases as PAPP-A level decreases. For pregnant women with a low PAPP-A level, monitoring of fetal growth and doppler indices can help identify high risk of adverse obstetric outcomes. Even if the ultrasound examination is normal it does not rule out an adverse outcome. Increased surveillance during pregnancy and low dose aspirin with uterine artery doppler were introduced in the guidelines for management of pregnant women with low PAPP-A.