Guideline sources The following summarized guidelines for the evaluation and management of preeclampsia (PET) are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022; 2014; 2013), the American College of Obstetricians and Gynecologists (ACOG 2022), the Royal College of Obstetricians and Gynaecologists (RCOG 2022), the European Society of Cardiology (ESC 2021; 2018), the American Association for the Study of Liver Diseases (AASLD 2021), the U.S. Preventive Services Task Force (USPSTF 2021; 2017), the Hypertension Canada Guidelines (Hypertension Canada 2020), the World Health Organization (WHO 2020; 2018), the American College of Gastroenterology (ACG 2016), the Italian Association for the Study of the Liver (AISF 2016), the American Heart Association (AHA/ASA 2014), and the American College of Chest Physicians (ACCP 2012). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Calculator https://web.pathway.md/diseases/reckVan8GwMkQsPQx 1/11 6/29/23, 11:25 PM Preeclampsia Pathway American College of Obstetricia Guidelines 1. Screening and diagnosis Indications for screening, general principles: As per SOGC 2022 guidelines, screen pregnant females at a minimum for clinical risk markers for PET in early pregnancy. Obtain screening at 11-14 weeks of gestation, if testing is available, using a combination of clinical risk markers, uterine artery pulsatility index, and placental growth factor to individualize the risk of developing PET. B As per USPSTF 2017 guidelines, screen all pregnant females for PET with BP measurements throughout pregnancy. B Indications for screening (IUGR): obtain maternal surveillance for the development of PET with adverse features in patients diagnosed with IUGR due to uteroplacental vascular insufficiency. B Indications for screening (ICP): obtain BP monitoring for the development of PET in patients with intrahepatic cholestasis of pregnancy. B Diagnostic criteria: diagnose hypertension in pregnant patients with an office (or in-hospital) systolic BP 140 mmHg and/or diastolic BP 90 mmHg, based on the average of at least 2 measurements, taken at least 15 minutes apart, using the same arm. B Show 2 more 2. Classification and risk stratification Severity grading: As per ACG 2016 guidelines, elevate the diagnosis of PET to severe PET in the presence of hepatic involvement. B As per SOGC 2014 guidelines, diagnose severe PET in patients with 1 of the following severe complications: Situation Guidance Eclampsia Neurological complications Posterior reversible encephalopathy syndrome Cortical blindness Retinal detachment Glasgow Coma Scale < 13 Stroke TIA https://web.pathway.md/diseases/reckVan8GwMkQsPQx 2/11 6/29/23, 11:25 PM Preeclampsia Pathway Reversible ischemic neurological defect Severe hypertension despite the use of 3 antihypertensive agents Cardiorespiratory complications Hypoxemia/pulmonary edema Positive inotropic support Myocardial ischemia or infarction Blood product transfusion Hematological complications AKI Renal complications Creatinine > 150 mcmol/L with no prior renal disease New indication for dialysis INR > 2 in the absence of DIC or warfarin use Hepatic complications Hepatic hematoma or rupture Abruption with evidence of maternal or fetal compromise Fetoplacental complications Reverse ductus venosus A wave Stillbirth. B 3. Diagnostic investigations Laboratory testing: Obtain the following laboratory tests in early pregnancy in patients with preexisting hypertension: serum creatinine serum potassium fasting blood glucose urinalysis. B Show 3 more Screening for proteinuria: assess all pregnant females for proteinuria. B Show 6 more Electrocardiogram: obtain an ECG in early pregnancy in patients with preexisting hypertension, if not previously documented. B Fetal evaluation: Obtain pertinent fetal testing in patients with suspected PET, including the following: uterine artery Doppler velocimetry fetal monitoring deepest amniotic fluid pocket ultrasound assessment of fetal growth umbilical artery Doppler https://web.pathway.md/diseases/reckVan8GwMkQsPQx 3/11 6/29/23, 11:25 PM Preeclampsia Pathway ductus venous Doppler middle cerebral artery Doppler. B Show 3 more 4. Medical management Setting of care: As per SOGC 2022 guidelines, admit patients with severe hypertension or PET with 1 maternal adverse condition to an inpatient care. E As per ESC 2018 guidelines, admit pregnant patients with a systolic BP 170 mmHg or diastolic BP 110 mmHg to a hospital. B Management of non-severe hypertension, indications and targets: As per SOGC 2022 guidelines: Initiate antihypertensive therapy in pregnant patients with an average systolic BP 140 mmHg or diastolic BP 90 mmHg, regardless of the hypertensive disorder of pregnancy. B Target a diastolic BP of 85 mmHg in pregnant patients with chronic or gestational hypertension on antihypertensive therapy. B . Consider setting a similar target in patients with PET. B As per ESC 2018 guidelines, initiate antihypertensive therapy at systolic BP > 140 mmHg or diastolic BP > 90 mmHg in patients with gestational hypertension or preexisting hypertension superimposed by gestational hypertension, or with hypertension and subclinical organ damage or symptoms. Initiate treatment at systolic BP 150 mmHg or diastolic BP 95 mmHg in all other cases. B Management of non-severe hypertension, choice of agent: As per Hypertension Canada 2020 guidelines: Initiate antihypertensive therapy as monotherapy using any of the following first-line agents: oral labetalol oral methyldopa long-acting oral nifedipine other oral -blockers (acebutolol, metoprolol, pindolol, and propranolol). B Consider administering other antihypertensive drugs as second-line agents, including: clonidine hydralazine thiazide diuretics. C As per WHO 2020 guidelines, consider administering oral alpha-agonist (methyldopa) and - blockers as treatment options in patients with non-severe hypertension during pregnancy. As per ESC 2018 guidelines, administer any of the following agents for the treatment of hypertension in pregnancy: B methyldopa B https://web.pathway.md/diseases/reckVan8GwMkQsPQx 4/11 6/29/23, 11:25 PM Preeclampsia Pathway labetalol B calcium antagonists. B As per AISF 2016 guidelines, administer any of the following agents as first-line antihypertensive therapy in patients with PET: labetolol methyldopa nifedipine. A Management of non-severe hypertension, contraindicated agents: As per Hypertension Canada 2020 guidelines, do not use ACEIs and ARBs during pregnancy. D As per ESC 2018 guidelines, do not use ACEIs inhibitors, ARBs, and direct renin inhibitors during pregnancy. D As per ASA/AHA 2014 guidelines, do not use atenolol, ARBs, and direct renin inhibitors during pregnancy. D Management of severe hypertension: As per SOGC 2022 guidelines, initiate urgent antihypertensive therapy (oral or parenteral) in patients with severe hypertension (systolic BP 160 mmHg or diastolic BP 110 mmHg) in pregnancy or postpartum. B As per ESC 2018 guidelines: Admit pregnant patients with a systolic BP 170 mmHg or diastolic BP 110 mmHg to a hospital. B Administer IV labetalol or oral methyldopa or nifedipine for the management of severe hypertension. B As per WHO 2018 guidelines, decide on the choice and route of administration of an antihypertensive drug for severe hypertension during pregnancy based primarily on the prescribing clinician's experience with that particular drug, its cost and local availability. B As per AHA 2014 guidelines, administer safe and effective antihypertensive medications, such as methyldopa, labetalol, or nifedipine, with consideration of maternal and fetal side effects, for the treatment of severe hypertension during pregnancy. A Magnesium sulfate: As per SOGC 2022 guidelines, administer magnesium sulfate as first-line therapy for and prophylaxis against eclampsia in patients with PET and severe hypertension or adverse maternal conditions. A As per AISF 2016 guidelines, administer magnesium sulphate for seizure prophylaxis in patients with severe PET and for controlling seizures in eclampsia. A Landmark trials: MAGPIE In women who had not given birth or were 24 h postpartum with BP 140/90 mmHg and proteinuria 1+, magnesium sulfate was superior to placebo with respect to eclampsia. https://web.pathway.md/diseases/reckVan8GwMkQsPQx 5/11 6/29/23, 11:25 PM Preeclampsia Pathway Altman D et al. Lancet. 2002 Jun 1. Intravenous nitroglycerin: administer nitroglycerin IV infusion in patients with PET associated with pulmonary edema. B 5. Nonpharmacologic interventions Bed rest: avoid advising bed rest in patients with PET. D 6. Therapeutic procedures Platelet transfusion: consider administering platelet transfusion in patients with a platelet count < 20 10 /L before vaginal delivery or < 50 10 /L before Cesarean delivery, or at any time if there is excessive active bleeding, known platelet dysfunction, rapidly falling platelet count, or coagulopathy. B Timing of delivery: As per SOGC 2022 guidelines, offer expectant care from fetal viability to < 37+0 weeks of gestation in patients with chronic hypertension, unless there is an indication for birth. (strong, very low) Consider offering initiation of delivery at 38+0 to 39 weeks of gestation. Initiate delivery from 40+0 weeks of gestation. B Show 2 more As per SOGC 2021 guidelines: Offer delivery at 37 weeks of gestation in patients with PET, with close monitoring for the development of eclampsia and HELLP syndrome syndrome. E Perform expeditious delivery after maternal stabilization in patients with suspected HELLP syndrome syndrome or eclampsia. E As per ESC 2018 guidelines: Offer delivery at 37 weeks of gestation in patients with gestational hypertension or mild PET. B Perform expedite delivery in patients with PET and adverse conditions, such as visual disturbances or hemostatic disorders. B As per ACG 2016 guidelines, perform prompt delivery after 36 weeks to limit maternal and fetal complications in patients with severe PET. B As per AISF 2016 guidelines, perform early delivery at > 37 weeks of gestation or when maternal-fetal conditions are deteriorating in patients with PET. A 7. Patient education Pre-conception counseling: Consider providing pre-conception counseling in patients with pre-pregnancy hypertension to advise on individualized management during pregnancy. C https://web.pathway.md/diseases/reckVan8GwMkQsPQx 6/11 6/29/23, 11:25 PM Preeclampsia Pathway Replace ACEIs or angiotensin-receptor blockers with other antihypertensives in patients planning pregnancy unless there is a compelling clinical indication not to. B 8. Preventative measures Low-dose aspirin, general principles: As per SOGC 2022 guidelines, initiate low-dose aspirin of 81-162 mg/day, A preferably before 16 weeks of gestation, B taken at bedtime, B and discontinued by 36 weeks of gestation, in females at increased risk of PET. B Do not use low-dose aspirin in all other females. B As per USPSTF 2021 guidelines, initiate low-dose aspirin after 12 weeks of gestation for the prevention of PET in persons at high risk for PET. B As per ESC 2018 guidelines, initiate low-dose aspirin (100-150 mg daily) from 12 weeks to 36-37 weeks of gestation in females at high or moderate risk of PET. A Landmark trials: ASPRE In women with singleton pregnancies who are at high risk for preterm preeclampsia, aspirin was superior to placebo with respect to preterm preeclampsia. Rolnik DL et al. N Engl J Med. 2017 Aug 17. As per ACCP 2012 guidelines, initiate low-dose aspirin, starting from the second trimester, in pregnant patients at risk for PET. B Low-dose aspirin (history of hypertension): initiate low-dose aspirin, starting at 12 weeks of gestation and continued until delivery, in patients with chronic primary or secondary hypertension or previous pregnancy-related hypertension. A Low-dose aspirin (diabetes): initiate low-dose aspirin of 100-150 mg/day (162 mg/day may also be acceptable), starting at 12-16 weeks of gestation, to lower the risk of PET in patients with T1DM or T2DM. B Low-dose aspirin (advanced age pregnancy): initiate daily low-dose aspirin for the reduction of PET in pregnant patients aged 35 years in the setting of at least one other moderate risk factor. B Calcium supplementation: As per SOGC 2022 guidelines, consider initiating oral calcium supplementation (at least 500 mg/day) for the prevention of PET in all females with low dietary intake of calcium (< 900 mg/day). C As per WHO 2020 guidelines, initiate calcium supplementation pre-pregnancy for the prevention of PET and its complications only in the context of rigorous research. As per AHA 2014 guidelines, consider initiating oral calcium supplementation of 1 g/day for the prevention of PET in females with low dietary intake of calcium (< 600 mg/day). B https://web.pathway.md/diseases/reckVan8GwMkQsPQx 7/11 6/29/23, 11:25 PM Preeclampsia Pathway Vitamin D supplementation: do not offer vitamin D supplementation above recommended daily doses for adults for the prevention of PET. D Exercising: advise exercising for the prevention of PET in all females. B Weight control: consider advising limitation of weight gain to < 6.8 kg in females with obesity. C 9. Follow-up and surveillance Postpartum care: As per SOGC 2022 guidelines: Evaluate patients with new or worsening hypertension and/or symptoms of PET accordingly as patients may develop PET for the first time postpartum. E Consider prescribing the following antihypertensive drugs in lactating females: labetalol methyldopa nifedipine enalapril or captopril. C As per AHA 2014 guidelines, continue antihypertensive therapy in patients with chronic hypertension after giving birth, with dosage adjustments to reflect the decrease in volume of distribution and GFR occurring after delivery. Obtain careful monitoring for the development of postpartum PET. B Follow-up: As per SOGC 2022 guidelines, assess BP regularly (at least twice) in the first 2 weeks after delivery in patients with hypertension. E Show 2 more As per ESC 2021 guidelines, consider obtaining periodic screening for hypertension and diabetes mellitus in patients with a history of PET and/or pregnancy-induced hypertension. C As per AISF 2016 guidelines, recognize that breastfeeding is not contraindicated in patients with PET on antihypertensive therapy with nifedipine, labetalol, atenolol, methyldopa, captopril, or enalapril. B As per AHA 2014 guidelines, consider assessing all females starting 6 months to 1 year postpartum, as well as females past childbearing age, for a history of PET/eclampsia as it increases the risk of future hypertension and stroke 1-30 years after delivery. C Evaluate for and treat cardiovascular risk factors including hypertension, obesity, smoking, and dyslipidemia. C Clinical findings Patient demographics Symptoms Age > 35 Blurry vision https://web.pathway.md/diseases/reckVan8GwMkQsPQx 8/11 6/29/23, 11:25 PM Preeclampsia Pathway Epigastric pain Past medical history Flashing lights Headache Antiphospholipid syndrome Heartburn Autoimmune disorders Memory impairment CKD Nausea Diabetes mellitus Photophobia Hypertension RUQ pain Hypothyroidism Seizure Nulliparity Visual disturbances Obesity Vomiting SLE Weight gain Thrombophilia Vitamin D deficiency Past obstetric history Family history Advanced maternal age pregnancy Preeclampsia Gestational trophoblastic disease Vital signs Hellp syndrome Hypertension IUGR O2 saturation Multiple gestation Placental abruption Neurological exam Stillbirth Altered mental status Social history Hyperreflexia Cocaine use Genitourinary exam Methamphetamine use urine output Tobacco use Hematological findings Vascular exam Coagulopathy Peripheral edema Schistocytes Ocular exam blood platelet count Choroidal ischemia Lab findings serum LDH serum TBIL serum creatinine serum transaminases serum uric acid soluble fms-like tyrosine kinase 1 urine protein placental growth factor serum albumin https://web.pathway.md/diseases/reckVan8GwMkQsPQx 9/11 6/29/23, 11:25 PM Preeclampsia Pathway Imaging findings Pulmonary edema Studies 2019 PHOENIX In women with late preterm preeclampsia from 34 to 37 weeks' gestation, planned delivery was superior to expectant management with respect to the composite outcome of maternal death and systolic BP 160 mmHg. Lucy C Chappell et al. Lancet. 2019 Sep 28. 2017 ASPRE In women with singleton pregnancies who are at high risk for preterm preeclampsia, aspirin was superior to placebo with respect to preterm preeclampsia. Rolnik DL et al. N Engl J Med. 2017 Aug 17. Show 2 more References 1. Laura A Magee, Graeme N Smith, Christine Bloch et al. Guideline No. 426 Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management. J Obstet Gynaecol Can. 2022 May;44 5 547 571.e1. Open 2. Bushnell C, McCullough LD, Awad IA et al. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 May;45 5 1545 88. Open 3. Magee LA, Pels A, Helewa M et al. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can. 2014 May;36 5 416 41. Open 4. Andrea Lausman, John Kingdom, MATERNAL FETAL MEDICINE COMMITTEE. 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Open https://web.pathway.md/diseases/reckVan8GwMkQsPQx 10/11 6/29/23, 11:25 PM Preeclampsia Pathway 10. Doreen M Rabi, Kerry A McBrien, Ruth Sapir-Pichhadze et al. Hypertension Canada's 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children. Can J Cardiol. 2020 May;36 5 596 624. Open 11. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018 Sep 7;39 34 3165 3241. Open 12. Italian Association for the Study of the Liver AISF , Italian Association for the Study of the Liver AISF. AISF position paper on liver disease and pregnancy. Dig Liver Dis. 2016 Feb;48 2 120 37. Open 13. No authors listed. WHO recommendation on Calcium supplementation before pregnancy for the prevention of pre-eclampsia and its complications Internet]. Geneva: World Health Organization; 2020. Open 14. Frank L J Visseren, Fran ois Mach, Yvo M Smulders et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021 Sep 7;42 34 3227 3337. Open 15. Monika Sarkar, Carla W Brady, Jaquelyn Fleckenstein et al. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Jan;73 1 318 365. Open 16. Shannon M Bates, Ian A Greer, Saskia Middeldorp et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141 2 Suppl):e691S- e736S. Open 17. No authors listed. WHO recommendations on drug treatment for non-severe hypertension in pregnancy Internet]. Geneva: World Health Organization; 2020. Open 18. US Preventive Services Task Force, Karina W Davidson, Michael J Barry et al. Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: US Preventive Services Task Force Recommendation Statement. JAMA. 2021 Sep 28;326 12 1186 1191. Open 19. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 20. Sotiriadis A, Hernandez-Andrade E, da Silva Costa F et al. ISUOG Practice Guidelines: role of ultrasound in screening for and follow-up of preeclampsia. Ultrasound Obstet Gynecol. 2019 Jan;53 1 7 22. Open 21. Lucy C Chappell, Peter Brocklehurst, Marcus E Green et al. Planned early delivery or expectant management for late preterm pre-eclampsia PHOENIX a randomised controlled trial. Lancet. 2019 Sep 28;394 10204 1181 1190. Open 22. No authors listed. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin Summary, Number 222. Obstet Gynecol. 2020 Jun;135 6 1492 1495. Open 23. Mark A Brown, Laura A Magee, Louise C Kenny et al. Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice. Hypertension. 2018 Jul;72 1 24 43. Open https://web.pathway.md/diseases/reckVan8GwMkQsPQx 11/11