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Copyright (c) 2024 Shaykhah Abdulaziz Majed Aldawsari, Mohamed Ali Abdallah Hawi, Nadiah Othman Mohammed Moussa Hakami, Hajar Yahya Ali Nabbash, Faizah Ali Hadadi, Abdulrahman Raja Al Harbi, Ashwag Owid Alenezi, Mohammed Ayidh Alotaibi, Mohammed Abuhadeen Aljubran, Hassan Abdoh Mohammed Sawadi, Mohammed Dughyyim Alharbi, Ahmed Mohammed Eshwi, Fawaz Abdullah Alshammari

This work is licensed under a Creative Commons Attribution 4.0 International License.
Artificial Intelligence-Based Early Warning Systems for Preeclampsia: A Narrative Review of the Integration of Ocular Signs and Oral Health
Corresponding Author(s) : Shaykhah Abdulaziz Majed Aldawsari
Saudi Journal of Medicine and Public Health, Vol. 1 No. 2 (2024)
Abstract
Background: Preeclampsia (PE) remains a leading cause of maternal and perinatal morbidity and mortality worldwide. Its pathophysiology involves systemic endothelial dysfunction and inflammation, yet early detection remains challenging due to heterogeneous clinical presentations. Aim: This narrative review synthesizes evidence on AI-based early warning systems (AI-EWS) for PE by integrating novel data streams: ocular signs (optometry), periodontal disease (dentistry), vital signs and patient education (nursing), electronic health records (health informatics), and pharmacologic protocols (pharmacy), within maternal and child health (M&CH) risk stratification. Methods: A structured literature search (2015–2024) in PubMed, Scopus, and IEEE Xplore identified 40 peer-reviewed articles. Thematic synthesis across disciplines was performed. Results: Retinal vascular changes detected via deep learning, periodontal inflammatory markers, and longitudinal vital sign trajectories improve AI-EWS predictive accuracy (AUC 0.85–0.94). Nursing-led education enhances adherence to monitoring. Pharmacy protocols integrated with AI alerts optimize timely magnesium sulfate administration. Conclusion: Multidisciplinary AI-EWS can transform antenatal surveillance, but prospective validation and implementation science are needed.
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- Alnasser, B. H., Alkhaldi, N. K., Alghamdi, W. K., Alghamdi, F. T., ALNasser, B. H., Alghamdi, W., & Alghamdi, F. (2023). The potential association between periodontal diseases and adverse pregnancy outcomes in pregnant women: a systematic review of randomized clinical trials. Cureus, 15(1). DOI: 10.7759/cureus.33216
- Brown, M. A., Magee, L. A., Kenny, L. C., Karumanchi, S. A., McCarthy, F. P., Saito, S., ... & Ishaku, S. (2018). Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension, 72(1), 24-43. https://doi.org/10.1161/HYPERTENSIONAHA.117.10803
- Corbella, S., Taschieri, S., Del Fabbro, M., Francetti, L., Weinstein, R., & Ferrazzi, E. (2016). Adverse pregnancy outcomes and periodontitis: A systematic review and meta-analysis exploring potential association. Quintessence Int, 47(3), 193-204. doi: 10.3290/j.qi.a34980
- De Borre, M., Che, H., Yu, Q., Lannoo, L., De Ridder, K., Vancoillie, L., ... & Thienpont, B. (2023). Cell-free DNA methylome analysis for early preeclampsia prediction. Nature Medicine, 29(9), 2206-2215. https://doi.org/10.1038/s41591-023-02510-5
- Gare, J., Kanoute, A., Meda, N., Viennot, S., Bourgeois, D., & Carrouel, F. (2021). Periodontal conditions and pathogens associated with pre-eclampsia: a scoping review. International journal of environmental research and public health, 18(13), 7194. https://doi.org/10.3390/ijerph18137194
- Gestational, H. (2020). Preeclampsia: ACOG practice bulletin, number 222. Obstet Gynecol, 135(6), e237-e60.
- Gianfrancesco, M. A., Tamang, S., Yazdany, J., & Schmajuk, G. (2018). Potential biases in machine learning algorithms using electronic health record data. JAMA internal medicine, 178(11), 1544-1547. doi:10.1001/jamainternmed.2018.3763
- Gulshan, V., Peng, L., Coram, M., Stumpe, M. C., Wu, D., Narayanaswamy, A., ... & Webster, D. R. (2016). Development and validation of a deep learning algorithm for detection of diabetic retinopathy in retinal fundus photographs. jama, 316(22), 2402-2410. doi:10.1001/jama.2016.17216
- Hartnett, E., Haber, J., Krainovich-Miller, B., Bella, A., Vasilyeva, A., & Kessler, J. L. (2016). Oral health in pregnancy. Journal of Obstetric, Gynecologic & Neonatal Nursing, 45(4), 565-573. https://doi.org/10.1016/j.jogn.2016.04.005
- Hong, Y. M., Lee, J., Cho, D. H., Jeon, J. H., Kang, J., Kim, M. G., ... & Kim, J. K. (2023). Predicting preterm birth using machine learning techniques in oral microbiome. Scientific Reports, 13(1), 21105. https://doi.org/10.1038/s41598-023-48466-x
- Jin, Y., Guo, H., Wang, J., & Song, A. (2020). A hybrid system based on LSTM for short-term power load forecasting. Energies, 13(23), 6241. https://doi.org/10.3390/en13236241
- Liu, W., Qiu, W., Huang, Z., Zhang, K., Wu, K., Deng, K., ... & Fang, F. (2022). Identification of nine signature proteins involved in periodontitis by integrated analysis of TMT proteomics and transcriptomics. Frontiers in Immunology, 13, 963123. https://doi.org/10.3389/fimmu.2022.963123
- Madianos, P. N., Bobetsis, Y. A., & Offenbacher, S. (2013). Adverse pregnancy outcomes (APO s) and periodontal disease: pathogenic mechanisms. Journal of clinical periodontology, 40, S170-S180. https://doi.org/10.1111/jcpe.12082
- Magee, L. A., von Dadelszen, P., Singer, J., Lee, T., Rey, E., Ross, S., ... & Moutquin, J. M. (2016). The CHIPS randomized controlled trial (Control of Hypertension in Pregnancy Study) is severe hypertension just an elevated blood pressure?. Hypertension, 68(5), 1153-1159. https://doi.org/10.1161/HYPERTENSIONAHA.116.07862
- Magee, L. A., & Von Dadelszen, P. (2018, November). State-of-the-art diagnosis and treatment of hypertension in pregnancy. In Mayo Clinic Proceedings (Vol. 93, No. 11, pp. 1664-1677). Elsevier. https://doi.org/10.1016/j.mayocp.2018.04.033
- Mandel, J. C., Kreda, D. A., Mandl, K. D., Kohane, I. S., & Ramoni, R. B. (2016). SMART on FHIR: a standards-based, interoperable apps platform for electronic health records. Journal of the american medical informatics association, 23(5), 899-908. https://doi.org/10.1093/jamia/ocv189
- Manna, S., Scheel, J., Noone, A., McElwain, C. J., Scaife, C., Gupta, S., ... & McCarthy, F. P. (2023). A proteomic profile of the healthy human placenta. Clinical Proteomics, 20(1), 1. https://doi.org/10.1186/s12014-022-09388-4
- Marić, I., Tsur, A., Aghaeepour, N., Montanari, A., Stevenson, D. K., Shaw, G. M., & Winn, V. D. (2020). Early prediction of preeclampsia via machine learning. American Journal of Obstetrics & Gynecology MFM, 2(2), 100100. https://doi.org/10.1016/j.ajogmf.2020.100100
- Maugeri, A., Barchitta, M., & Agodi, A. (2023). How wearable sensors can support the research on foetal and pregnancy outcomes: a scoping review. Journal of Personalized Medicine, 13(2), 218. https://doi.org/10.3390/jpm13020218
- Niklander, S., Bordagaray, M. J., Fernández, A., & Hernández, M. (2021). Vascular endothelial growth factor: a translational view in oral non-communicable diseases. Biomolecules, 11(1), 85. https://doi.org/10.3390/biom11010085
- Obermeyer, Z., & Emanuel, E. J. (2016). Predicting the future—big data, machine learning, and clinical medicine. The New England journal of medicine, 375(13), 1216. https://doi.org/10.1056/NEJMp1606181
- Obermeyer, Z., Powers, B., Vogeli, C., & Mullainathan, S. (2019). Dissecting racial bias in an algorithm used to manage the health of populations. Science, 366(6464), 447-453. https://doi.org/10.1126/science.aax2342
- Oganov, A. C., Seddon, I., Jabbehdari, S., Uner, O. E., Fonoudi, H., Yazdanpanah, G., ... & Arevalo, J. F. (2023). Artificial intelligence in retinal image analysis: Development, advances, and challenges. Survey of ophthalmology, 68(5), 905-919. https://doi.org/10.1016/j.survophthal.2023.04.001
- Okusanya, B. O., Oladapo, O. T., Long, Q., Lumbiganon, P., Carroli, G., Qureshi, Z., ... & Gülmezoglu, A. M. (2016). Clinical pharmacokinetic properties of magnesium sulphate in women with pre‐eclampsia and eclampsia. BJOG: An International Journal of Obstetrics & Gynaecology, 123(3), 356-366. https://doi.org/10.1111/1471-0528.13753
- Phipps, E. A., Thadhani, R., Benzing, T., & Karumanchi, S. A. (2019). Pre-eclampsia: pathogenesis, novel diagnostics and therapies. Nature Reviews Nephrology, 15(5), 275-289. https://doi.org/10.1038/s41581-019-0119-6
- Poplin, R., Varadarajan, A. V., Blumer, K., Liu, Y., McConnell, M. V., Corrado, G. S., ... & Webster, D. R. (2018). Prediction of cardiovascular risk factors from retinal fundus photographs via deep learning. Nature biomedical engineering, 2(3), 158-164. https://doi.org/10.1038/s41551-018-0195-0
- Rajalakshmi, R., Arulmalar, S., Usha, M., Prathiba, V., Kareemuddin, K. S., Anjana, R. M., & Mohan, V. (2015). Validation of smartphone based retinal photography for diabetic retinopathy screening. PloS one, 10(9), e0138285. https://doi.org/10.1371/journal.pone.0138285
- Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: pathophysiology, challenges, and perspectives. Circulation research, 124(7), 1094-1112. https://doi.org/10.1161/CIRCRESAHA.118.313276
- Rolnik, D. L., Nicolaides, K. H., & Poon, L. C. (2022). Prevention of preeclampsia with aspirin. American journal of obstetrics and gynecology, 226(2), S1108-S1119. https://doi.org/10.1016/j.ajog.2020.08.045
- Sandall, J., Hatem, M., Devane, D., Soltani, H., & Gates, S. (2009). Discussions of findings from a Cochrane review of midwife-led versus other models of care for childbearing women: continuity, normality and safety. Midwifery, 25(1), 8-13. doi:10.1016/j.midw.2008.12.002
- Ting, D. S. W., Cheung, C. Y. L., Lim, G., Tan, G. S. W., Quang, N. D., Gan, A., ... & Wong, T. Y. (2017). Development and validation of a deep learning system for diabetic retinopathy and related eye diseases using retinal images from multiethnic populations with diabetes. Jama, 318(22), 2211-2223. doi:10.1001/jama.2017.18152
- Topol, E. J. (2019). High-performance medicine: the convergence of human and artificial intelligence. Nature medicine, 25(1), 44-56. https://doi.org/10.1038/s41591-018-0300-7
- Vyas, D. A., Eisenstein, L. G., & Jones, D. S. (2020). Hidden in plain sight—reconsidering the use of race correction in clinical algorithms. New England Journal of Medicine, 383(9), 874-882. DOI: 10.1056/NEJMms2004740
- Wang, G., Zhang, Y., Li, S., Zhang, J., Jiang, D., Li, X., ... & Du, J. (2021). A machine learning-based prediction model for cardiovascular risk in women with preeclampsia. Frontiers in Cardiovascular Medicine, 8, 736491. https://doi.org/10.3389/fcvm.2021.736491
- Wolff, R. F., Moons, K. G., Riley, R. D., Whiting, P. F., Westwood, M., Collins, G. S., ... & PROBAST Group†. (2019). PROBAST: a tool to assess the risk of bias and applicability of prediction model studies. Annals of internal medicine, 170(1), 51-58. https://doi.org/10.7326/M18-1376
- Wong, T. Y., & Sabanayagam, C. (2019). The war on diabetic retinopathy: where are we now?. The Asia-Pacific Journal of Ophthalmology, 8(6), 448-456. DOI: 10.1097/APO.0000000000000267
- World Health Organization. (2021). WHO antenatal care recommendations for a positive pregnancy experience. Nutritional interventions update: zinc supplements during pregnancy. World Health Organization.
- Wright, D., Wright, A., Tan, M. Y., & Nicolaides, K. H. (2022). When to give aspirin to prevent preeclampsia: application of Bayesian decision theory. American Journal of Obstetrics and Gynecology, 226(2), S1120-S1125. https://doi.org/10.1016/j.ajog.2021.10.038
- Zeisler, H., Llurba, E., Chantraine, F., Vatish, M., Staff, A. C., Sennström, M., ... & Verlohren, S. (2016). Predictive value of the sFlt-1: PlGF ratio in women with suspected preeclampsia. New England Journal of Medicine, 374(1), 13-22. DOI: 10.1056/NEJMoa1414838
References
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Brown, M. A., Magee, L. A., Kenny, L. C., Karumanchi, S. A., McCarthy, F. P., Saito, S., ... & Ishaku, S. (2018). Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension, 72(1), 24-43. https://doi.org/10.1161/HYPERTENSIONAHA.117.10803
Corbella, S., Taschieri, S., Del Fabbro, M., Francetti, L., Weinstein, R., & Ferrazzi, E. (2016). Adverse pregnancy outcomes and periodontitis: A systematic review and meta-analysis exploring potential association. Quintessence Int, 47(3), 193-204. doi: 10.3290/j.qi.a34980
De Borre, M., Che, H., Yu, Q., Lannoo, L., De Ridder, K., Vancoillie, L., ... & Thienpont, B. (2023). Cell-free DNA methylome analysis for early preeclampsia prediction. Nature Medicine, 29(9), 2206-2215. https://doi.org/10.1038/s41591-023-02510-5
Gare, J., Kanoute, A., Meda, N., Viennot, S., Bourgeois, D., & Carrouel, F. (2021). Periodontal conditions and pathogens associated with pre-eclampsia: a scoping review. International journal of environmental research and public health, 18(13), 7194. https://doi.org/10.3390/ijerph18137194
Gestational, H. (2020). Preeclampsia: ACOG practice bulletin, number 222. Obstet Gynecol, 135(6), e237-e60.
Gianfrancesco, M. A., Tamang, S., Yazdany, J., & Schmajuk, G. (2018). Potential biases in machine learning algorithms using electronic health record data. JAMA internal medicine, 178(11), 1544-1547. doi:10.1001/jamainternmed.2018.3763
Gulshan, V., Peng, L., Coram, M., Stumpe, M. C., Wu, D., Narayanaswamy, A., ... & Webster, D. R. (2016). Development and validation of a deep learning algorithm for detection of diabetic retinopathy in retinal fundus photographs. jama, 316(22), 2402-2410. doi:10.1001/jama.2016.17216
Hartnett, E., Haber, J., Krainovich-Miller, B., Bella, A., Vasilyeva, A., & Kessler, J. L. (2016). Oral health in pregnancy. Journal of Obstetric, Gynecologic & Neonatal Nursing, 45(4), 565-573. https://doi.org/10.1016/j.jogn.2016.04.005
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Liu, W., Qiu, W., Huang, Z., Zhang, K., Wu, K., Deng, K., ... & Fang, F. (2022). Identification of nine signature proteins involved in periodontitis by integrated analysis of TMT proteomics and transcriptomics. Frontiers in Immunology, 13, 963123. https://doi.org/10.3389/fimmu.2022.963123
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Manna, S., Scheel, J., Noone, A., McElwain, C. J., Scaife, C., Gupta, S., ... & McCarthy, F. P. (2023). A proteomic profile of the healthy human placenta. Clinical Proteomics, 20(1), 1. https://doi.org/10.1186/s12014-022-09388-4
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Maugeri, A., Barchitta, M., & Agodi, A. (2023). How wearable sensors can support the research on foetal and pregnancy outcomes: a scoping review. Journal of Personalized Medicine, 13(2), 218. https://doi.org/10.3390/jpm13020218
Niklander, S., Bordagaray, M. J., Fernández, A., & Hernández, M. (2021). Vascular endothelial growth factor: a translational view in oral non-communicable diseases. Biomolecules, 11(1), 85. https://doi.org/10.3390/biom11010085
Obermeyer, Z., & Emanuel, E. J. (2016). Predicting the future—big data, machine learning, and clinical medicine. The New England journal of medicine, 375(13), 1216. https://doi.org/10.1056/NEJMp1606181
Obermeyer, Z., Powers, B., Vogeli, C., & Mullainathan, S. (2019). Dissecting racial bias in an algorithm used to manage the health of populations. Science, 366(6464), 447-453. https://doi.org/10.1126/science.aax2342
Oganov, A. C., Seddon, I., Jabbehdari, S., Uner, O. E., Fonoudi, H., Yazdanpanah, G., ... & Arevalo, J. F. (2023). Artificial intelligence in retinal image analysis: Development, advances, and challenges. Survey of ophthalmology, 68(5), 905-919. https://doi.org/10.1016/j.survophthal.2023.04.001
Okusanya, B. O., Oladapo, O. T., Long, Q., Lumbiganon, P., Carroli, G., Qureshi, Z., ... & Gülmezoglu, A. M. (2016). Clinical pharmacokinetic properties of magnesium sulphate in women with pre‐eclampsia and eclampsia. BJOG: An International Journal of Obstetrics & Gynaecology, 123(3), 356-366. https://doi.org/10.1111/1471-0528.13753
Phipps, E. A., Thadhani, R., Benzing, T., & Karumanchi, S. A. (2019). Pre-eclampsia: pathogenesis, novel diagnostics and therapies. Nature Reviews Nephrology, 15(5), 275-289. https://doi.org/10.1038/s41581-019-0119-6
Poplin, R., Varadarajan, A. V., Blumer, K., Liu, Y., McConnell, M. V., Corrado, G. S., ... & Webster, D. R. (2018). Prediction of cardiovascular risk factors from retinal fundus photographs via deep learning. Nature biomedical engineering, 2(3), 158-164. https://doi.org/10.1038/s41551-018-0195-0
Rajalakshmi, R., Arulmalar, S., Usha, M., Prathiba, V., Kareemuddin, K. S., Anjana, R. M., & Mohan, V. (2015). Validation of smartphone based retinal photography for diabetic retinopathy screening. PloS one, 10(9), e0138285. https://doi.org/10.1371/journal.pone.0138285
Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: pathophysiology, challenges, and perspectives. Circulation research, 124(7), 1094-1112. https://doi.org/10.1161/CIRCRESAHA.118.313276
Rolnik, D. L., Nicolaides, K. H., & Poon, L. C. (2022). Prevention of preeclampsia with aspirin. American journal of obstetrics and gynecology, 226(2), S1108-S1119. https://doi.org/10.1016/j.ajog.2020.08.045
Sandall, J., Hatem, M., Devane, D., Soltani, H., & Gates, S. (2009). Discussions of findings from a Cochrane review of midwife-led versus other models of care for childbearing women: continuity, normality and safety. Midwifery, 25(1), 8-13. doi:10.1016/j.midw.2008.12.002
Ting, D. S. W., Cheung, C. Y. L., Lim, G., Tan, G. S. W., Quang, N. D., Gan, A., ... & Wong, T. Y. (2017). Development and validation of a deep learning system for diabetic retinopathy and related eye diseases using retinal images from multiethnic populations with diabetes. Jama, 318(22), 2211-2223. doi:10.1001/jama.2017.18152
Topol, E. J. (2019). High-performance medicine: the convergence of human and artificial intelligence. Nature medicine, 25(1), 44-56. https://doi.org/10.1038/s41591-018-0300-7
Vyas, D. A., Eisenstein, L. G., & Jones, D. S. (2020). Hidden in plain sight—reconsidering the use of race correction in clinical algorithms. New England Journal of Medicine, 383(9), 874-882. DOI: 10.1056/NEJMms2004740
Wang, G., Zhang, Y., Li, S., Zhang, J., Jiang, D., Li, X., ... & Du, J. (2021). A machine learning-based prediction model for cardiovascular risk in women with preeclampsia. Frontiers in Cardiovascular Medicine, 8, 736491. https://doi.org/10.3389/fcvm.2021.736491
Wolff, R. F., Moons, K. G., Riley, R. D., Whiting, P. F., Westwood, M., Collins, G. S., ... & PROBAST Group†. (2019). PROBAST: a tool to assess the risk of bias and applicability of prediction model studies. Annals of internal medicine, 170(1), 51-58. https://doi.org/10.7326/M18-1376
Wong, T. Y., & Sabanayagam, C. (2019). The war on diabetic retinopathy: where are we now?. The Asia-Pacific Journal of Ophthalmology, 8(6), 448-456. DOI: 10.1097/APO.0000000000000267
World Health Organization. (2021). WHO antenatal care recommendations for a positive pregnancy experience. Nutritional interventions update: zinc supplements during pregnancy. World Health Organization.
Wright, D., Wright, A., Tan, M. Y., & Nicolaides, K. H. (2022). When to give aspirin to prevent preeclampsia: application of Bayesian decision theory. American Journal of Obstetrics and Gynecology, 226(2), S1120-S1125. https://doi.org/10.1016/j.ajog.2021.10.038
Zeisler, H., Llurba, E., Chantraine, F., Vatish, M., Staff, A. C., Sennström, M., ... & Verlohren, S. (2016). Predictive value of the sFlt-1: PlGF ratio in women with suspected preeclampsia. New England Journal of Medicine, 374(1), 13-22. DOI: 10.1056/NEJMoa1414838