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OB
CMECNE

Diagnosing Preeclampsia – Key Definitions and ACOG Guidelines

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Define the blood pressure criteria required to make a diagnosis of hypertension
2. Identify characteristics of severe preeclampsia on the labor floor

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

WHAT IS IT?

Preeclampsia is a pregnancy specific hypertensive disease with multi-system involvement. It usually occurs after 20 weeks of gestation and can be superimposed on another hypertensive disorder. While preeclampsia was historically defined by the new onset of hypertension in combination with proteinuria, some women will present with hypertension and multisystemic signs in the absence of proteinuria. The presence of multisystemic signs is an indication of disease severity.

SUMMARY:

Diagnostic Criteria

Blood Pressure Criteria

  • Hypertension – systolic BP > 140 mm hg or diastolic BP > 90 mm hg or both
    • On two occasions at least 4 hours apart after 20 weeks gestations with previously normal BP
    • Considered ‘mild’ until diastolic BP > 110mm hg or systolic BP ≥160 mm Hg
  • Severe Hypertension – systolic BP > 160 mm hg or diastolic BP > 110 mm hg or both
    • Can confirm using a short time interval (e.g., minutes) to facilitate timely antihypertensive therapy

Note: Gestational Hypertension

  • ACOG defines gestational hypertension as “hypertension without proteinuria or severe features develops after 20 weeks of gestation and blood pressure levels return to normal in the postpartum period”
  • Caution and close follow-up is warranted as up to a half of women with gestational hypertension will go on to manifest signs an symptoms consistent with preeclampsia
  • Women with severe gestational hypertension, even in the absence of proteinuria should be managed similar to women with severe preeclampsia
  • ACOG states

Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher) should be diagnosed with preeclampsia with severe features.

Proteinuria Criteria

  • 24 hour urine collection >300 mg protein or
  • Single voided urine protein/creatinine ratio ≥0.3
  • Dipstick reading of 2+ (use only if other quantitative methods not available)

Preeclampsia Definitions

Preeclampsia

  • Hypertension and proteinuria or
  • In absence of proteinuria, new-onset hypertension with the new onset of any of the following
    • Thrombocytopenia: Platelets <100 x 109/L
    • Renal insufficiency: serum creatinine >1.1 mg/dl or doubling of serum creatinine in the absence of other renal disease
    • Impaired liver function: Elevated blood concentrations of liver transaminases to twice normal concentration
    • Pulmonary edema
    • Neuro: Unexplained new-onset headache unresponsive to medication (without an alternative diagnosis) or visual symptoms

Preeclampsia with severe features

  • Preeclampsia diagnosis, above, with any of the following
    • Severe hypertension
      • On two occasions at least 4 hours apart while on bed rest (unless already on antihypertensive therapy)
    • Thrombocytopenia: Platelets <100 x 109/L
    • Impaired liver function (without an alternative diagnosis): Elevated liver transaminases greater than twice upper limit of normal or severe persistent right upper quadrant or epigastric pain not responsive to medications
    • Progressive renal insufficiency: serum creatinine >1.1 mg/dl or doubling of serum creatinine in the absence of other renal disease
    • Pulmonary edema
    • Neuro: Unexplained new-onset headache unresponsive to medication (without an alternative diagnosis) or visual symptoms

Note: The following are not diagnostic criteria for the diagnosis of preeclampsia or preeclampsia with severe features

  • Clinically evident edema
  • Rapid weight gain
  • Massive proteinuria
    • Does not qualify as a ‘severe feature’
  • Fetal growth restriction
    • ACOG states that while it is important to monitor fetal status, FGR in the setting of all other fetal assessment being within normal limits (e.g., AFV, Doppler), expectant management ‘may be reasonable’ if mother and fetus appear stable and no other clinical indication is present that would indicate the need for early delivery
  • Uric acid
    • Hyperuricemia in hypertensive pregnancy is not a diagnostic marker, but is an important finding as a risk factor for adverse maternal and fetal outcomes
      • Small for gestational age (SGA) infant
      • Prematurity
      • Risk for adverse maternal outcomes if include patients with preeclampsia and risks increase with increasing concentration of uric acid
    • May be warranted in the setting of ‘diagnostic dilemmas’ such as diagnosing superimposed preeclampsia in the setting of chronic hypertension

Learn More – Primary Sources

ACOG Practice Bulletin 222: Gestational Hypertension and Preeclampsia

National Partnership for Maternal Safety Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

Plasma uric acid remains a marker of poor outcome in hypertensive pregnancy: a retrospective cohort study

Pre-eclampsia: pathophysiology and clinical implications

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Related ObG Topics:

ACOG Preeclampsia Guidelines: Antenatal Management and Timing of Delivery
Eclampsia and Role of Magnesium Sulfate
ACOG Guidance: Emergency Treatment for Severe Hypertension in Pregnancy
Aspirin Treatment for Women at Risk for Preeclampsia – ACOG, SMFM and USPSTF Recommendations
ASPRE Trial: A Combined Risk Algorithm and Use of Aspirin to Prevent Preterm Preeclampsia
Does Aspirin Decrease the Risk of Preterm Birth in Preeclampsia?
When to Introduce Aspirin to Reduce Risks of Preeclampsia?

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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