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Preeclampsia

Key sources
The following summarized guidelines for the evaluation and management of preeclampsia are prepared by our editorial team based on guidelines from the European Association for the Study of the Liver (EASL 2023), the European Society of Hypertension (ESH 2023), the American Academy of Family Physicians (AAFP 2023), 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 U.S. Preventive Services Task Force (USPSTF 2021; 2017), the American Association for the Study of Liver Diseases (AASLD 2021), the World Health Organization (WHO 2020; 2018), the Hypertension Canada (HC 2020), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 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).
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Guidelines

1.Screening and diagnosis

Indications for screening, general population, SOGC: obtain screening at least for clinical risk markers for preeclampsia 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 preeclampsia.
B
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  • Indications for screening (at-risk population)

  • Indications for screening (intrahepatic cholestasis of pregnancy)

  • Diagnostic criteria

2.Classification and risk stratification

Severity grading: as per ACG 2016 guidelines, elevate the diagnosis of preeclampsia to severe preeclampsia in the presence of hepatic involvement.
B

3.Diagnostic investigations

Laboratory testing: as per EASL 2023 guidelines, obtain maternal assessment in patients with preeclampsia, including clinical features (BP and proteinuria) and biochemical tests as components of multivariate models, such as the fullPIERS or PREP models.
A

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  • Screening for proteinuria

  • Abdominal ultrasound

  • ECG

  • Fetal evaluation

4.Medical management

Setting of care: as per SOGC 2022 guidelines, admit patients with severe hypertension or preeclampsia with ≥ 1 maternal adverse condition to an inpatient care.
E

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  • Management of non-severe hypertension (indications and targets)

  • Management of non-severe hypertension (choice of agent)

  • Management of non-severe hypertension (contraindicated agents)

  • Management of severe hypertension

  • Magnesium sulfate

  • Intravenous nitroglycerin

5.Nonpharmacologic interventions

Bed rest: avoid advising bed rest in patients with preeclampsia.
D

6.Therapeutic procedures

Platelet transfusion: as per EASL 2023 guidelines, consider administering platelet transfusion in pregnant patients with a platelet count < 100×10⁹/L to reduce the risk of abnormal coagulation and adverse maternal outcomes associated with preeclampsia.
B

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  • Timing of delivery

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
Replace ACEIs or ARBs with other antihypertensives in patients planning pregnancy unless there is a compelling clinical indication not to.
B

8.Preventative measures

Weight control: consider advising limitation of weight gain to < 6.8 kg in females with obesity.
C

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  • Exercising

  • Low-dose aspirin (general principles)

  • Low-dose aspirin (history of hypertension)

  • Low-dose aspirin (diabetes)

  • Low-dose aspirin (advanced age pregnancy)

  • Vitamin D supplementation

  • Calcium supplementation

9.Follow-up and surveillance

Serial blood pressure monitoring: consider obtaining home BP monitoring as an alternative to conventional office BP measurement to achieve BP control in patients with gestational or preexisting hypertension.
C

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  • Postpartum monitoring

  • Postpartum antihypertensive therapy

  • Breastfeeding

  • Long-term surveillance