The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice.

Abstract

This set of recommendations from ISSHP is designed to assist clinicians throughout the world in the recognition and management of the hypertensive disorders of pregnancy; the document includes sections written by those working in low and middle income countries so as to ensure applicability in all parts of the world. Some key points include: ISSHP does not recommend classifying pre-eclampsia as ‘mild’ or ‘severe’ because the condition may progress rapidly and unpredictably. Proteinuria is not mandatory for a diagnosis of pre-eclampsia. The HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low platelets) is one (serious) manifestation of pre-eclampsia and not a separate disorder. ISSHP supports first trimester screening for risk of pre-eclampsia when this can be integrated into the local health system, although the cost effectiveness of this approach remains to be established. ISSHP recommends that women with established strong clinical risk factors for pre-eclampsia (i.e., prior pre-eclampsia, chronic hypertension, pre-gestational diabetes, maternal BMI >30 kg/m2, antiphospholipid syndrome and receipt of assisted reproduction) be treated, ideally before 16 weeks but definitely before 20 weeks, with low dose aspirin (defined as 75–162 mg/day, as studied in RCTs). ISSHP recommends at this stage against the routine clinical use of ‘rule-in’ or ‘rule-out’ tests (specifically PlGF or sFLT-1/PlGF ratio) for pre-eclampsia. Regardless of the hypertensive disorder of pregnancy, blood pressure requires urgent treatment in a monitored setting when severe (>160/110 mmHg). For pre-eclampsia, target diastolic blood pressure is 85 mmHg in the office/clinic (and systolic blood pressure of 110–140 mmHg). Women with pre-eclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs or symptoms, should receive magnesium sulphate (MgSO4) for convulsion prophylaxis. Annual medical review is advised life-long and all such women should adopt a healthy lifestyle that includes exercise, eating well and aiming for ideal body weight.