International Society For The Study Of Hypertension In Pregnancy Research Articles

Implementing Preeclampsia Screening in Switzerland (IPSISS): First Results from a Multicentre Registry

Introduction: The Fetal Medicine Foundation (FMF) London developed a first trimester combined screening algorithm for preterm preeclampsia (pPE) that allows a significantly higher detection of pregnancies at risk compared to conventional screening by maternal risk factors only. The aim of this trial is to validate this screening model in the Swiss population in order to implement this screening into routine first trimester ultrasound and to prescribe low-dose aspirin 150 mg (LDA) in patients at risk for pPE. Therefore, a multicentre registry study collecting and screening pregnancy outcome data was initiated in 2020; these are the preliminary results. Methods: Between June 1, 2020, and May 31, 2021, we included all singleton pregnancies with pPE screening at the hospitals of Basel, Lucerne, and Bern. Multiple of medians of uterine artery pulsatility index (UtA-PI), mean arterial pressure (MAP), placental growth factor (PlGF), and pregnancy-associated plasma protein A (PAPP-A) as well as risks were analysed as calculated by each centre’s software and recalculated on the FMF online calculator for comparative reasons. Statistical analyses were performed by GraphPad Version 9.1. Results: During the study period, 1,027 patients with singleton pregnancies were included. 174 (16.9%) had a risk >1:100 at first trimester combined screening. Combining the background risk, MAP, UtA-PI, and PlGF only, the cut-off to obtain a screen positive rate (SPR) of 11% is ≥1:75. Outcomes were available for 968/1,027 (94.3%) of all patients; 951 resulted in live birth. Fifteen (1.58%) developed classical preeclampsia (PE), 23 (2.42%) developed PE according to the International Society for the Study of Hypertension in Pregnancy (ISSHP) definition. Conclusion: First trimester combined screening for PE and prevention with LDA results in a low prevalence of PE. The screening algorithm performs according to expectations; however, the cut-off of >1:100 results in a SPR above the accepted range and a cut-off of ≥1:75 should be considered for screening. More data are needed to evaluate, if these results are representative for the general Swiss population.

Vitamin D Deficiency and Its Clinical Results in Preeclamptic Mothers and Their Babies

Introduction: Vitamin D deficiency during pregnancy may lead to many health problems by negatively affecting the metabolism of the newborn and the mother, such as infantile rickets, poor fetal and neonatal growth and development, gestational diabetes, and preeclampsia. We aimed to investigate the levels and clinical results of vitamin D in preeclamptic mothers and their babies.Methods: The study group consisted of 42 preeclamptic mothers, and their babies diagnosed with preeclampsia according to the International Society for the Study of Hypertension in Pregnancy (ISSHP) criteria, while the control group consisted of 49 healthy mothers and babies with similar gestational age and birth weight. All pregnant women participating in the study were routinely taking 1200 IU of vitamin D3 daily supplements. The cord blood vitamin D level of both groups of newborns was measured and the results were statistically compared.Results: The birth week, weight, and height averages and APGAR score averages measured at the first minutes of the babies in the study group (preeclamptic mother babies) were statistically significantly lower than those of the babies in the control group (babies of healthy mothers) (p=0.001, p=0.001, p<0.001, p=0.004, respectively). Vitamin D and calcium levels of the mothers in the study group were lower than those of the mothers in the control group. When the infants were examined, only the level of vitamin D was statistically significantly lower in infants in the patient group (p<0.001, p<0.001, p=0.001, respectively).Conclusion: There is consistent evidence of an association between low vitamin D concentrations and adverse preeclampsia outcomes. Since vitamin D deficiency is more common in preeclamptic mothers and their infants, higher-dose vitamin D supplementation than routine may be recommended to the patients.

Should angiogenic markers be included in diagnostic criteria of superimposed pre-eclampsia in women with chronic hypertension?

Although the most recent guidance from the International Society for the Study of Hypertension in Pregnancy (ISSHP) has highlighted the role of angiogenic marker assessment in the diagnosis of pre-eclampsia (PE) in women with chronic hypertension, the ISSHP has withheld recommending its implementation due to the limited available evidence in this group of women. Therefore, we aimed to investigate the value of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) assessment in women with chronic hypertension and suspected superimposed PE. This was a retrospective analysis of prospectively collected data recorded in an electronic database between January 2013 and October 2019. Women with chronic hypertension and singleton pregnancy who had suspected superimposed PE were included. Superimposed PE was suspected in women presenting with worsening hypertension, epigastric pain, new-onset edema, dyspnea or neurological symptoms. The exclusion criteria were delivery within 1 week after assessment for reasons other than PE, chronic kidney disease, history of cardiac disease, fetal aneuploidy, genetic syndrome or major structural anomaly and missing pregnancy outcome. Maternal serum angiogenic markers (sFlt-1, PlGF and sFlt-1/PlGF ratio) were measured. The primary outcome was the utility of angiogenic markers in the prediction of superimposed PE. Predictive accuracy was assessed for superimposed PE diagnosed at different timepoints, including within 1 week after assessment and any time before birth. The secondary outcome was comparison of adverse maternal and perinatal outcomes between women with superimposed PE diagnosed according to the traditional ISSHP criteria and those diagnosed according to extended criteria including angiogenic markers. The predictive accuracy of each angiogenic marker was assessed using receiver-operating-characteristics-curve analysis. Area under the curve (AUC) values were compared using De Long's test. A sensitivity analysis was planned for gestational age at assessment. The association of various variables with composite adverse maternal and perinatal outcomes was assessed using binomial regression. The study included 142 pregnant women with chronic hypertension and suspected superimposed PE, of whom 25 (17.6%) developed PE within 1 week after assessment, 52 (36.6%) developed PE at any timepoint before birth and 90 (63.4%) delivered without PE. Maternal serum angiogenic imbalance was associated significantly with superimposed PE diagnosed according to the ISSHP criteria within 1 week or at any time after assessment (P < 0.001 for both). The predictive accuracy of maternal serum sFlt-1/PlGF ratio for superimposed PE diagnosed within 1 week after assessment was superior to that of maternal serum PlGF level (AUC, 0.91 vs 0.86; P = 0.032). The addition of angiogenic imbalance to the traditional ISSHP diagnostic criteria was associated with an increase in the detection rate (35.1% increase; 95% credible interval (CrI), 16.6-53.6%) and positive (9.6% increase; 95% CrI, 0.0-20.6%) and negative (3.1% increase; 95% CrI, 1.3-4.9%) predictive values for composite adverse maternal outcome, with high posterior probabilities of an increase in each predictive accuracy parameter (> 99.9%, 95.6% and > 99.9%, respectively), without a meaningful decrease in specificity. The addition of angiogenic imbalance improved the detection rate for composite adverse perinatal outcome (20.6% increase; 95% CrI, 0.0-42.2%), with a high posterior probability (96.9%). There was a corresponding drop in specificity (5.7% decrease; 95% CrI, -2.3% to 13.6%), with a posterior probability of 91.8%. In women with chronic hypertension and suspected superimposed PE, addition of maternal serum angiogenic markers to the traditional diagnostic criteria for superimposed PE improved significantly the sensitivity for the prediction of both maternal and perinatal adverse outcomes. Implementation of angiogenic marker assessment in the evaluation of pregnant women with chronic hypertension should therefore be considered. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Prevalence and Pregnancy Outcome of Preeclampsia Using International Society for the Study of Hypertension in Pregnancy 2018 Criteria in Comparison to 2001

Introduction: Criteria of preeclampsia (PE) have evolved over years to increase the prediction of adverse pregnancy outcomes. Revised International Society for the Study of Hypertension in Pregnancy (ISSHP) 2018 criteria incorporates organ system dysfunction with or without proteinuria. This study aims to determine changes in prevalence and pregnancy outcome of PE diagnosed by revised criteria compared to traditional ones. Methods: This was a cross-sectional study conducted in the department of Obstetrics and Gynecology from July to October 2021. Women with hypertensive disorders in pregnancy (HDP) were classified according to ISSHP 2001 and 2018 criteria to study the prevalence and pregnancy outcomes. Data were analyzed using Statistical Package for the Social Sciences version 21. Results: There was an increase in the prevalence of PE applying ISSHP 2018 criteria (12.6% vs 4.6%). The proportion of cases of PE in HDP increased from 19.4% to 52.7%. Preterm delivery was more in the group diagnosed using old criteria compared to revised criteria (52% vs 33.8%). Maternal morbidity like operative delivery, severe hypertension, eclampsia, abruptio, intrauterine growth restriction, were more in women diagnosed only with proteinuria. Low birth weight, Apgar less than 7 at one and five minutes, perinatal morbidity and mortality, were also more in PE diagnosed using old criteria compared to revised criteria. Conclusion: The prevalence of PE increased without changes in the pregnancy outcome when revised ISSHP 2018 criteria were applied over the traditional 2001.

A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre‐eclampsia

A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre‐eclampsia

Diagnosis and treatment of hypertensive disorders of pregnancy: a narrative review

The paper overviews classification, diagnosis and treatment of hypertensive disorders of pregnancy and early postpartum period (chronic hypertension (HTN), gestational HTN, pre-eclampsia) provided by different societies of cardiology and obstetrics and gynecology. The definition of pre-eclampsia offered by the International Society for the Study of Hypertension in Pregnancy (ISSHP) in 2018 and supported by the International Federation of Gynecology and Obstetrics (FIGO) in 2019, its screening and prevention are considered. All treatment options of moderate and severe HTN in pregnancy are reviewed. A new US Food and Drug Administration (FDA) classification system of drug therapy for pregnancy and lactation Pregnancy and Lactation Labelling Rule (PLLR, 2015) is presented. Treatment goals of HTN and blood pressure (BP) thresholds in pregnancy as well as risk factors, causes, clinical presentation, diagnostic workup and management of hypertensive emergencies in pregnancy are provided. We discuss the evidence of BP ≥ 130/80 mmHg as a factor of high maternal and neonatal risks proposed by the American College of Cardiology/American Heart Association (2017) as the HTN criteria in pregnancy.

Chronic Hypertension in Pregnancy

(Am J Obstet Gynecol. 2020;222:532–541) New guidelines for the management of chronic hypertension have been published in the last 3 years by the American College of Obstetricians and Gynecologists (ACOG), The American College of Cardiology (ACC), The American Heart Association (AHA), and the International Society for the Study of Hypertension in Pregnancy (ISSHP). The authors compiled this work to review the evidence supporting these new guidelines and to provide critiques on areas that need further research.

PLACENTAL HEMODYNAMIC ASSESSMENT IN WOMEN WITH SEVERE PREECLAMPSIA IN SECOND- AND THIRD-TRIMESTER PREGNANCY BY 3D POWER QUANTITATIVE DOPPLER ULTRASOUND

Objective: The present study analyzed the fetal–placental hemodynamic parameters in women with severe preeclampsia in second- and third-trimester pregnancy with a view to developing effective predictive indicators for preeclampsia and providing support for the prenatal clinical treatment of preeclampsia. Materials and Methods: From January 2015 to January 2019, 160 pregnant women diagnosed with severe preeclampsia at Xiangyang First People’s Hospital were recruited as the study group. The diagnostic criteria for preeclampsia were in accordance with the guidelines of the International Society for the Study of Hypertension in Pregnancy (ISSHP). A sample of 160 healthy pregnant women with normal blood pressure were selected as the control group. The GE Voluson E8 and E10 four-dimensional (4D) ultrasonic diagnostic instruments and the three-dimensional (3D) power Doppler in angio-quantitative mode were used to measure the hemodynamic parameters of the placenta, left uterine artery (LUA), right uterine artery (RUA), middle cerebral artery (MCA), umbilical artery (UA), and ductus venosus (DV) in the two groups. The above parameters were analyzed statistically using SPSS 22.0. Results: The systolic/diastolic velocity ratio (S/D), pulsatility index (PI), and resistance index (RI) of the MCA in the study group were lower than those of normal subjects of the same gestational age (P &lt; 0.05). These parameters in the UA were higher in the study group than those in normal subjects (P &lt; 0.05). The ratios between the peak ventricular systolic velocity and the peak atrial systolic velocity (S/A), pulsatility index for the vein (PIV), pre-load index (PLI), and peak velocity index for the vein (PVIV) in the DV were significantly different between the study and normal groups (P &lt; 0.05). The placental vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were lower in the study group than those in normal subjects of the same gestational age (P &lt; 0.05). There were good correlations between VI, VFI and RUA, PI, with correlation coefficients of −0.697 and −0.702, respectively. FI was the indicator that had the highest diagnostic efficacy for severe preeclampsia. The predictive sensitivity of the FI with a cut-off value of 34.92 was 96.3%, and the corresponding specificity was 86.9%. Conclusions: Placental FI had the highest predictive efficacy for severe preeclampsia and provides a reliable quantitative indicator and data support for preeclampsia management. 3D power quantitative Doppler ultrasound provides a novel avenue for the study of severe preeclampsia.

The WHO Safe Childbirth Checklist implementation: impact on the prescription of magnesium sulphate through a one-year longitudinal study

BackgroundPreeclampsia is a relatively frequent condition during pregnancy and childbirth. The administration of magnesium sulphate as a prophylactic and treatment measure is an evidence-based practice for eclampsia; however, it is not consistently used, compromising the health of pregnant women. This study aimed to assess compliance with recommendations of the International Society for the Study of Hypertension in Pregnancy (ISSHP) for the use of MgSO4 in pregnant women with preeclampsia, before and after the implementation of the World Health Organization Safe Childbirth Checklist (SCC).MethodsThis quasi-experimental study was conducted between July 2015 and July 2016 at a third-level maternity hospital in northeastern Brazil, where the SCC was implemented. Compliance (underuse and overuse of MgSO4) was assessed in biweekly samples of 30 deliveries assessed 6 months before and 6 months after SCC implementation, using indicators based on international guidelines. A total of 720 deliveries were assessed over 1 year using an ad hoc application for reviewing medical records. Aggregated adequate use was estimated for the study period, and the time series measurements were compared to a control chart to assess change.ResultsThe incidence of preeclampsia was 39.9% (287/720). Among these, 64.8% (186/287) had severe signs or symptoms and needed MgSO4. Underuse (no prescription when needed) of MgSO4 was observed in 74.7% (139/186) of women who needed the drug. Considering all women, non-compliance with the prescription protocol (underuse and overuse) was 20.0% (144/720). After introducing the SCC, the use of MgSO4 in women with preeclampsia with severe features increased from 19.1 to 34.2% (p = 0.025). Longitudinal analysis showed a significant (p < 0.05) ascending curve of adequate use of MgSO4 after the SCC was implemented.ConclusionsCompliance with recommendations for the use of MgSO4 in preeclampsia was low, but improved after implementation of the SCC. Interventions to improve compliance based on diagnosis and treatment reminders may help in the implementation of this good practice.

Serum levels of tumor necrosis factor- α and interleukin -10, and their clinical correlates in women with pre-eclampsia/eclampsia in Ahmadu Bello University Teaching Hospital

Background: Pre-eclampsia is a pregnancy-specific disorder characterized by the onset of hypertension and proteinuria after the 20th week of gestation. It is characterized by an exaggerated maternal inflammatory response with a preponderance of cell-mediated immune response. Tumor necrosis factor-alpha (TNF-α) is a pro-inflammatory cytokine that induces apoptosis and restrains differentiation. Defective trophoblastic invasion is now identified as the key etiology of pre-eclampsia. The objective of this study was to determine the serum levels TNF-α and interleukin 10 (IL-10) in women with pre-eclampsia/eclampsia and the relationship between these cytokines and the severity of the disease. Patients and Method: This was a case-control study carried out in Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Forty-eight patients with a diagnosis of pre-eclampsia/eclampsia were recruited as cases. The diagnosis was according to the International Society for the Study of Hypertension in Pregnancy (ISSHP) criteria. For each case, a healthy pregnant control was selected, after matching for age, gestational age, and parity. Blood samples were taken and assayed for TNF-α and IL 10 using enzyme-linked immunosorbent assay. Data were analyzed using SPSS v 20. A P value Results: The prevalence of pre-eclampsia/eclampsia in ABUTH Zaria is 5.1%. Nulliparous women constituted 65.9% of the patients. Thirty-five percent of the women were between 20 and 24 years of age. The mean serum levels of TNF-α in women with pre-eclampsia/ eclampsia and controls were 294.8 ± 146 pg/mL and 176 ± 35.5 pg/mL, respectively. The mean serum levels of IL-10 in patients and controls with pre-eclampsia were 13.9 ± 5.7 pg/mL and 33.0 ± 11.0 pg/mL, respectively. The levels of TNF-α correlated positively with the severity of the disease. The serum levels of IL-10 did not correlate with disease severity. Conclusion: The prevalence of pre-eclampsia/eclampsia is high in ABUTH. The disease is characterized by an exaggerated inflammatory response in women in Zaria. Use of anti- TNF-α drugs may possibly have a role in the prevention of pre-eclampsia.

1044: A search for modifiable risk factors of severe maternal morbidity in hypertensive diseases of pregnancy

To identify modifiable risk factors for organ dysfunction (OD) in women with hypertensive diseases of pregnancy (HDP) using the definition of organ dysfunction by the International Society for the Study of Hypertension in Pregnancy (ISSHP). We performed a retrospective case control study of pregnant women who received care at the Regional hospital in Accra, Ghana. The hospital receives referrals from 108 facilities that account for 91% of transfers. Women presenting with hypertension; chronic, gestational, pre-eclampsia or eclampsia over nonconsecutive 10-week period from 2016-2017 were included for analysis. Medical records were systematically reviewed to identify antepartum and intrapartum factors, and maternal and neonatal outcomes. Women meeting criteria for organ dysfunction (creatinine > 1.02 mg/ dL (90 umol/L), transaminitis ± right upper quadrant or epigastric pain, neurological complications, thrombocytopenia, coagulopathy, or hemolysis (ISSHP definition) were statistically compared to women without these factors, and a third indeterminate group. There were 1125 gravidas admitted to the labor ward during the study period and 117 had HDP (10.4%). Organ dysfunction was present in 51 (43.6%) and no OD in 19 (16.2%) women. There were 47 (40.2) indeterminate women with HDP. Factors associated with OD were multiparity (p= 0.01), history of HDP (p= 0.01), gestational age at delivery (p= 0.02), preterm delivery (p= 0.01), antihypertensive medication prior to transfer (p= 0.01), and diastolic blood pressure at time of transfer (p= 0.04). Multiple other factors were not associated with OD (Table). This study, in a middle resource country, suggests that gestational age at delivery is a potential modifiable risk factor for organ dysfunction and diastolic blood pressure prior to referral to the tertiary center is a modifiable risk factor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Angiogenic profiling in HELLP syndrome cases with or without hypertension and proteinuria

ObjectivesAngiogenic profiling with the use of sFlt-1/PlGF ratio (soluble fms-like tyrosine kinase-1/placental growth factor) can be helpful to characterize women with signs of impending preeclampsia (PE). However, little is known about the angiogenic profile of pregnancies complicated by HELLP syndrome. The aim of this study was to examine the relationship of angiogenic profiles in cases of HELLP syndrome with and without classical signs of preeclampsia. Study designThe angiogenic profile of pregnant women with singleton gestation and isolated PE (group 1), PE associated with HELLP syndrome (group 2), and isolated HELLP syndrome (group 3) from 01/2011 to 03/2018, were compared. To overcome gestational age dependent angiogenic behavior, cases (group 3) were matched 1:2 with cases from group 1 and 2. Matching criteria was gestational age (±1 week). PE and HELLP syndrome were defined according to the international Society for the Study of Hypertension in Pregnancy (ISSHP) statement 2014. ResultsDuring the observational period, 244 women could be included in the study. Of those, 237 (97.1%) were diagnosed with PE. In 42 cases (17.2%) PE was associated with HELLP syndrome while 7 (2.9%) patients were diagnosed with isolated HELLP syndrome. Angiogenic profiles in terms of sFlt-1/PlGF ratios differed significantly between the three groups, showing highest levels in group 2 (PE/HELLP) while cases with isolated HELLP demonstrated the lowest ratios and sFlt-1 values (p = 0.01). ConclusionWe conclude that isolated HELLP syndrome is rare and seems to be a particular entity expressing a different angiogenic behaviour compared to classical PE or PE associated with HELLP syndrome.

Early- and Late-Onset Preeclampsia: A Comprehensive Cohort Study of Laboratory and Clinical Findings according to the New ISHHP Criteria.

Recently, the diagnostic criteria of preeclampsia have been changed. No studies are available in the literature that analyzed in detail the differences between early-onset preeclampsia (EOP) and late-onset preeclampsia (LOP), taking into account the International Society for the Study of Hypertension in Pregnancy (ISSHP) criteria. Thus, we sought to retrospectively investigate in detail the differences in clinical and laboratory outcomes between EOP and LOP diagnosed according to the ISSHP criteria. A retrospective cohort study was conducted in 214 women with singleton pregnancies and preeclampsia admitted to the Department of Obstetrics and Perinatology of the University Hospital in Kraków, Poland, from 2013 to 2017 (113 (52.8%) women with EOP and 101 (47.2%) women with LOP). Electronic medical records were reviewed for demographics and medical history, laboratory tests, and delivery and neonatal data. Patients with preeclampsia accounted for 1.7% of the women who delivered during the study period. The EOP and LOP groups did not differ in the distribution of risk factors for preeclampsia. The most common risk factor was primiparity, which was observed in 72.0% of cases. Regarding the ISSHP diagnostic criteria, the two groups differed in the incidence of fetal growth restriction (p=0.0009), hemolysis (p=0.0416), and neurological complications (p=00342), which were found more often in the EOP group. In addition, the EOP group had more frequent occurrence of severe cardiorespiratory (p < 0.0001) and hematological (p=0.0127) complications, adverse fetoplacental conditions (p < 0.0001), and severe fetoplacental complications (p=0.0003). Children born to women with EOP had lower Apgar scores (p < 0.001) and higher rates of intraventricular hemorrhage (p < 0.0001), respiratory disorders requiring mechanical ventilation (p < 0.0001), and early (p=0.0004) and late sepsis (p=0.002). EOP differed from LOP in terms of maternal and perinatal adverse outcomes. The observed higher rates of fetoplacental adverse conditions and severe complications indicate a significant contribution of impaired placentation to the etiopathogenesis of EOP.

Does pre-eclampsia without proteinuria lead to different pregnancy outcomes than pre-eclampsia with proteinuria?

The Japanese Society for the Study of Hypertension in Pregnancy revised the diagnostic criteria for pre-eclampsia (PE) to conform to those of the International Society for the Study of Hypertension in Pregnancy (ISSHP) in 2018. This study aimed to investigate whether pregnancy outcomes differ based on the presence of proteinuria and validate the adoption of the ISSHP criteria in Japan. This is a retrospective study involving 308 women diagnosed with hypertensive disorders of pregnancy at a tertiary center. They were divided into the following groups: PE with proteinuria (n = 218), PE without proteinuria (n = 45) and gestational hypertension (n = 45) according to the ISSHP criteria for comparison of pregnancy outcomes. Applying the ISSHP criteria increased the number of pregnant women diagnosed as having PE by 14.6% (45 women). The difference in the rate of composite maternal complications between the two groups was unremarkable, with 33 cases (15.1%) in the PE with proteinuria group and 9 cases (20%) in the PE without proteinuria group. Moreover, composite neonatal complications occurred in 37 cases (17%) of PE with proteinuria group and 6 cases (13.3%) of PE without proteinuria group, showing remarkably similar incidence rate in the two groups. Women with PE with and without proteinuria had significantly earlier deliveries and lower neonatal birth weight than those with gestational hypertension. Pregnancy outcomes of PE with and without proteinuria were almost similar although their incidence increased, confirming its validity for adaptation of the ISSHP criteria in Japan.

The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention.

The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention.

Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice.

These recommendations from the International Society for the Study of Hypertension in Pregnancy (ISSHP) are based on available literature and expert opinion. It is intended that this be a living document, to be updated when needed as more research becomes available to influence good clinical practice. Unfortunately, there is a relative lack of high-quality randomized trials in the field of hypertension in pregnancy compared with studies in essential hypertension outside of pregnancy, and ISSHP encourages greater funding and uptake of collaborative research in this field. Accordingly, the quality of evidence for the recommendations in this document has not been graded although relevant references and explanations are provided for each recommendation. The document will be a living guideline, and we hope to be able to grade recommendations in the future. Guidelines and recommendations for management of hypertension in pregnancy are typically written for implementation in an ideal setting. It is acknowledged that in many parts of the world, it will not be possible to adopt all of these recommendations; for this reason, options for management in less-resourced settings are discussed separately in relation to diagnosis, evaluation, and treatment. This document has been endorsed by the International Society of Obstetric Medicine and the Japanese Society for the Study of Hypertension in Pregnancy. All units managing hypertensive pregnant women should maintain and review uniform departmental management protocols and conduct regular audits of maternal and fetal outcomes. The cause(s) of preeclampsia and the optimal clinical management of the hypertensive disorders of pregnancy remain uncertain; therefore, we recommend that every hypertensive pregnant woman be offered an opportunity to participate in research, clinical trials, and follow-up studies. ### Classification 1. Hypertension in pregnancy may be chronic (predating pregnancy or diagnosed before 20 weeks of pregnancy) or de novo (either preeclampsia or gestational hypertension). 2. Chronic hypertension is associated with adverse …

Pregnancy outcomes in women with previous gestational hypertension: A cohort study to guide counselling and management.

In pregnant women with previous gestational hypertension: to compare the prevalence of preeclampsia as defined by the 2001 versus the 2014 International Society for the Study of Hypertension in Pregnancy (ISSHP) criteria, to determine the rates of fetal growth restriction (FGR) as defined, not only by birthweight centile, but in combination with fetal ultrasound studies and, finally, to determine rates of other related outcomes such as gestational diabetes (GDM) and obstetric cholestasis (OC). This was a retrospective observational study based at the Antenatal Hypertension Clinic, Kings College Hospital, London. Routinely collected data of 773 women booked between 2011 and 2016 with a history of gestational hypertension was analysed. All women were normotensive at booking and those with chronic hypertension were excluded. Hypertensive disorders of pregnancy (ISSHP-2014), FGR, GDM. Forty-nine percent developed one or more pregnancy complications, of which 72% were hypertensive disorders of pregnancy, 25.8% preeclampsia, 25% GDM and 19% FGR. Overall recurrence rate of preeclampsia was 12.5% (ISSHP-2014). Higher blood pressure and body mass index at booking were associated with higher risk of preeclampsia and GDM. Earlier gestation of previous hypertension was associated with higher risk of preeclampsia and FGR. The ISSHP-2014 compared to the 2001 guidelines classified 56% more women as having preeclampsia. Pregnant women with a history of gestational hypertension have a 49% chance of developing a complication related to a hypertensive disorder, GDM and OC. The rate of preeclampsia was more than doubled if the updated ISSHP-2014 definition was used.

A call to action for data definition standardisation and core outcome sets.

Systematic reviews, which form the pinnacle of the ‘levels of evidence pyramid’, synthesise knowledge and serve to evolve evidence-based medical practice. Duffy and colleagues present a systematic review of maternal and offspring outcome reporting across 79 randomised controlled trials (RCTs) evaluating 55 various therapeutic interventions for pre-eclampsia. These RCTs reported 119 different outcomes (72 maternal and 47 offspring outcomes) for 31 615 maternal and 28 172 offspring participants. Surprisingly, some critical yet easily acquirable outcomes were often not reported: for example, maternal mortality and offspring mortality were reported in 14% and 35% of RCTs, respectively. Fewer than half of all RCTs reported maternal and offspring harm, only six RCTs reported childhood outcomes (with the longest duration of follow-up being 2 years), and three RCTs performed economic evaluations. Relatively recently, it has become apparent to researchers and clinicians that variation and heterogeneity in reported outcomes among related RCTs create impediments to aggregating data. This problem stems from several sources, including multiple potential definitions for a single outcome and from wide variations in reporting from the panoply of potential outcomes. For example, an RCT on the treatment of postpartum haemorrhage may define it as 500 mL for vaginal delivery and 1000 mL for caesarean delivery, whereas another may use a definition of 1000 mL in the first 24 hours, regardless of delivery mode. A study on interventions for pre-eclampsia may base the definition of severe pre-eclampsia upon the American Congress of Obstetricians and Gynecologists (ACOG), the UK National Institute for Health and Care Excellence (NICE), the International Society for the Study of Hypertension in Pregnancy (ISSHP), or other recognised, but essentially different, guidelines. Concerted efforts to standardize clinical definitions, such as ACOG's reVITALize campaign, are needed to improve outcome reporting and aggregate analysis in subsequent systematic reviews (Menard et al. Obstet Gynecol 2014;124:150–3). The COMET Initiative (Core Outcome Measures in Effectiveness Trials), formed in Liverpool in 2010, is a database focused on studies for the development and implementation of standardised core outcomes sets (COSs), which are determined by consensus methodology involving multiple stakeholders and contain the minimum number of variables deemed critically important to a topic (Williamson & Clarke Cochrane Database Syst Rev 2012;5:ED000041). The CROWN Initiative (Core Outcomes in Women's Health) aims to form a consortium to promote the development of COSs in our specialty (Khan BJOG 2014;121:1181–2). At present, three COSs are endorsed by CROWN (epilepsy in pregnancy, preterm birth prevention, and maternity care), with many others in development. One significant limitation of systematic reviews is the potentially short shelf life: one study reported that 23% of systematic reviews needed updating within 2 years of publication (Shojania et al. Ann Intern Med 2007;147:224–33). Data definition standardisation, implementation of COSs, and data sharing via repositories (Coady et al. N Engl J Med 2017;376:1849–58) should accelerate our ability to make timely systematic review updates and changes to best practice. So, let this be a call to action for collaborative efforts among researchers, publishers, guideline makers, grant-making agencies, insurers, and patient advocacy groups for a further focus on the development of data definition standardisation and COSs in obstetrics and gynecology research. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

P 34 Does performance of mean arterial blood pressure for the screening of preeclampsia improve after controlling for the use of anti-hypertensive medication?

Question Mean arterial pressure (MAP) is a useful biomarker for the screening of preeclampsia (PE). However, MAP, a function of cardiac output and peripheral resistance, is dependent on other maternal characteristics and, for its effective use in screening, these need to be taken into account. One such characteristic is the use of anti-hypertensive medication. The aim of our study was to evaluate the impact of the use of anti-hypertensive medication on the performance of MAP as a screening tool for PE in pregnant women with chronic hypertension or a history of gestational hypertension. Methods A retrospective study was conducted on women with chronic hypertension (N = 478) and normotensive women with a history of gestational hypertension (N = 511) who booked with the Antenatal Hypertension Clinic, Kings College Hospital, London, between 2009–2016. Blood pressure was measured repeatedly antenatally using an automated device validated for use in pregnancy and PE. The more updated International Society for the Study of Hypertension in Pregnancy (ISSHP)-2014 definition of PE was used. We constructed probit Receiver Operating Characteristic Curves (ROC) models to determine the predictive capacity of MAP in women taking anti-hypertensive medication and in those who were not. Wald tests of the null hypothesis that the two ROC curves are equal at different false-positive rates were performed. Age and medication use were taken into account in the comparisons. Results The area under the curves (AUC) for the prediction of PE (p = Conclusion The ability of MAP to predict PE and renal dysfunction is significantly improved by controlling for the use of anti-hypertensive medication in a high-risk pregnant population.

P 33 Does the performance of mean arterial pressure for the screening of preeclampsia differ between women with chronic hypertension and women with a history of gestational hypertension?

Question Recent studies have demonstrated that different parameters of blood pressure may hold valuable information not only in the diagnosis of preeclampsia (PE) but also in identifying women in their first and second trimester at risk of developing PE later in the pregnancy. One such promising component is mean arterial blood pressure (MAP). This study aims to examine the prediction of MAP for PE, renal dysfunction, liver dysfunction and fetal growth restriction (FGR) in two groups of high-risk pregnant women: with chronic hypertension or a history of gestational hypertension. Methods A retrospective study was conducted on women with chronic hypertension ( N = 478) and normotensive women with a history of gestational hypertension ( N = 511) who booked with the Antenatal Hypertension Clinic, Kings College Hospital, London, between 2009–2016. Blood pressure was measured repeatedly antenatally using an automated device validated for use in pregnancy and PE. The updated International Society for the Study of Hypertension in Pregnancy (ISSHP)-2014 definition of PE was used. We constructed probit models to determine the predictive capacity of MAP by comparing the Receiver Operating Characteristic Curves (ROC) in the two groups. Wald tests of the null hypothesis that the two ROC curves are equal at different false-positive rates were performed. Age and medication use were taken into account in the comparisons. STATA 14.0 was used for the analysis. Results The area under the curves (AUC) for the prediction of PE ( p = p = 0.079) was 0.66 (95% CI: 0.62–0.71) and 0.79 (95% CI: 0.74–0.85) for women with chronic hypertension and history of gestational hypertension, respectively (Fig. 1). There were no differences found between the AUC for the prediction of FGR and liver dysfunction. Estimates were adjusted for age and medication use, with the latter being strongly associated with hypertension status. Conclusion The ability of MAP to predict PE and renal dysfunction is significantly affected by the woman’s hypertensive status, with improved performance in women with a history of gestational hypertension.