The classification, diagnosis and management of the hypertensive disorders of pregnancy: A revised statement from the ISSHP

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Introduction

There has never been a definite consensus on the classification and diagnostic criteria for the hypertensive disorders of pregnancy. This uncertainty is likely to have led to between-centre differences in rates of adverse maternal and foetal outcomes for the various hypertensive disorders in pregnancy, particularly pre-eclampsia.

In 2000, the International Society for the Study of Hypertension in Pregnancy (ISSHP) recognised that this lack of consensus was one reason for controversies concerning counselling, management and documentation of immediate and remote pregnancy outcomes. Accordingly, the Society appointed a committee that reviewed available classifications and endorsed and published an international recommendation for how these disorders should be classified and diagnosed in pregnancy [1]. The major stumbling block remained whether or not proteinuria should be retained as a sine qua non for the diagnosis of pre-eclampsia; the Society recommended that a broad definition, at times not including proteinuria, could be applied for the clinical definition of pre-eclampsia whilst the inclusion of proteinuria would ensure more specificity around the diagnosis when reporting clinical criteria for patients enrolled in scientific research. The purpose of this document is to update ISSHP thinking on this subject.

Section snippets

Why is there a need for an updated statement?

In the years since this report, there have been a number of developments relevant to diagnosis, classification and management of the hypertensive disorders in pregnancy. One problem is the emerging concept that pre-eclampsia may indeed have several subtypes, the final clinical manifestation being the result of a maternal constitutive response to either abnormal placental function or abnormal placentation [2]. Several clinical issues need be considered.

Firstly, there has been an international

Hypertension

Pre-eclampsia and gestational hypertension are characterised by the new onset of hypertension (>140 mmHg systolic or >90 mmHg diastolic) after 20 weeks gestation [11]; as such, it is important to have normal blood pressure documented either pre-pregnancy or at least in early pregnancy before there has been much pregnancy-related decrease in blood pressure. Otherwise, a normal first blood pressure measured between 16 and 20 weeks may result in a missed diagnosis of chronic hypertension.

When women

Prediction and prevention of pre-eclampsia

Many clinical, ultrasonographic, and laboratory parameters have been explored during early pregnancy as tools for predicting who will later develop pre-eclampsia; these include, amongst others [32], [33], [34], [35], [36]:

  • uterine artery doppler studies,

  • measurement of angiogenic factors (such as soluble Endoglin, sFlt-1 and sFLt-1/Placental Growth Factor ratio)

  • ADAM-12, plasma PAPP-A, PP 13, homocysteine, ADMA, uric acid and leptin,

  • Urinary albumin or calcium

Maternal characteristics that are

Prevention

No treatment to date can reliably prevent pre-eclampsia in all women; even the analyses of studies of large numbers of women using aspirin or calcium for prevention of pre-eclampsia remain open to differing interpretations.

On balance, we believe that for women considered to be at increased risk for pre-eclampsia on the basis of clinical factors mentioned above, both low dose aspirin and calcium (particularly in the setting of low calcium intake) are recommended for the prevention of

Management

ISSHP endorses the following key management points:

  • 1.

    Women with an initial diagnosis of pre-eclampsia should be admitted to hospital in all cases; following assessment in hospital, some women with pre-eclampsia may be managed in specialised outpatient settings, such as day assessment units or antepartum home care programs in hospitals with appropriate expertise.

  • 2.

    Clinical assessment of women with pre-eclampsia should include measurement of pulse oximetry where possible.

  • 3.

    Maternal blood tests should

Ethics statement

Ethics approval was not sought for this article.

Funding

The authors have no support or funding to report.

Competing interests

The authors have declared that no competing interests exist.

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