The impact of pre‐eclampsia definitions on the identification of adverse outcome risk in hypertensive pregnancy – analyses from the CHIPS trial (Control of Hypertension in Pregnancy Study)

Abstract

Objective To examine the association between pre‐eclampsia definition and pregnancy outcome. Design Secondary analysis of Control of Hypertension in Pregnancy Study (CHIPS) trial data. Setting International multicentre randomised controlled trial (RCT). Population In all, 987 women with non‐severe non‐proteinuric pregnancy hypertension. Methods We evaluated the association between pre‐eclampsia definitions and adverse pregnancy outcomes, stratified by hypertension type and blood pressure control. Main outcome measures Main CHIPS trial outcomes: primary (perinatal loss or high‐level neonatal care for >48 hours), secondary (serious maternal complications), birthweight <10th centile, severe maternal hypertension, delivery at <34 or <37 weeks, and maternal hospitalisation before birth. Results Of 979/987 women with informative data, 280 (28.6%) progressed to pre‐eclampsia defined restrictively by new proteinuria, and 471 (48.1%) to pre‐eclampsia defined broadly as proteinuria or one/more maternal symptoms, signs or abnormal laboratory tests. The broad (versus restrictive) definition had significantly higher sensitivities (range 62–79% versus 36–50%), lower specificities (range 53–65% versus 72–82%), and similar or higher diagnostic odds ratios and ‘true‐positive’ to ‘false‐positive’ ratios. Stratified analyses showed similar results. Addition of available fetoplacental manifestations (stillbirth or birthweight <10th centile) to the broad pre‐eclampsia definition improved sensitivity (74–87%). Conclusions A broad (versus restrictive) pre‐eclampsia definition better identifies women who develop adverse pregnancy outcomes. These findings should be replicated in a prospective study within routine healthcare to ensure that the anticipated increase in surveillance and intervention in a larger number of women with pre‐eclampsia is associated with improved outcomes, reasonable costs and congruence with women's values. Tweetable abstract A broad (versus restrictive) pre‐eclampsia definition better identifies the risk of adverse pregnancy outcomes.

A global view of hypertensive disorders and diabetes mellitus during pregnancy

“…This diagnostic shift will influence clinical management (for example, increased hospital admission and induction of labour) 17 . Although the debate is still ongoing on these new classification systems, studies published in 2021 revealed that a broad definition of pre-eclampsia could better identify women and babies at risk of adverse outcomes 22 , 23 .…”

The evolution of the diagnostic criteria of preeclampsia-eclampsia

“…A recurring theme in prospective studies 54,55 is that compared with a narrow definition (ie, hypertension and proteinuria), a broad definition has a higher sensitivity for identifying women who suffer complications but a lower specificity. Authors have supported this, as "the purpose of classification is to identify groups of women who require specific care," 55 such as closer monitoring.…”

Neuropilin-1 in the pathogenesis of preeclampsia, HIV-1, and SARS-CoV-2 infection: A review

“…PE is a human pregnancy disorder clinically manifesting with new-onset hypertension after 20 weeks of gestation ( Magee et al, 2021 ). Proteinuria is a common symptom of PE; however, it is not a criterion for diagnosis ( Brown et al, 2018 ; Magee et al, 2021 ).…”

“…PE is a human pregnancy disorder clinically manifesting with new-onset hypertension after 20 weeks of gestation ( Magee et al, 2021 ). Proteinuria is a common symptom of PE; however, it is not a criterion for diagnosis ( Brown et al, 2018 ; Magee et al, 2021 ). End-organ dysfunctions such as acute kidney injury, neurological symptoms, liver dysfunction, the HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), and/or uteroplacental dysfunction, such as fetal growth restriction (FGR), may also feature in PE ( Brown et al, 2018 ; Magee et al, 2021 ).…”

“…Proteinuria is a common symptom of PE; however, it is not a criterion for diagnosis ( Brown et al, 2018 ; Magee et al, 2021 ). End-organ dysfunctions such as acute kidney injury, neurological symptoms, liver dysfunction, the HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), and/or uteroplacental dysfunction, such as fetal growth restriction (FGR), may also feature in PE ( Brown et al, 2018 ; Magee et al, 2021 ). Globally, PE complicates 5-7% of pregnancies, often escalating to >10% in LMICs and is annually accountable for a substantial proportion of maternal and fetal mortality ( Wanderer et al, 2013 ; Brown et al, 2018 ).…”