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. Discuss the FIGO recommendations for first trimester screening for preterm preeclampsia
2. Describe preventative treatments for those at high risk for preterm preeclampsia

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 instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

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 7/1/2019 through 7/1/2021, 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.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

FIGO released first trimester preeclampsia screening guidance that provides recommendations for assessing risk based not only on clinical history and findings, but also biomarkers.  FIGO calls for universal screening for preeclampsia

All pregnant women should be screened for preterm PE during early pregnancy by the first‐trimester combined test with maternal risk factors and biomarkers as a one‐step procedure

Combined Tests for Preeclampsia

Best Combined Test (high risk defined as ≥ 1 in 100)

• Combination of clinical factors and biomarkers (see ASPRE summary in ‘Related ObG Topics’ below) including
  • Maternal risk factors
  • Mean arterial pressure (MAP)
  • serum placental growth factor (PlGF)
  • Uterine artery pulsatility index (UTPI)

Note: Calculator is open access and available in the ‘Learn More – Primary Sources’ below

PlGF and/or UTPI Not Available 

• Use maternal risk factors and MAP
• Do not use maternal risk factors alone
• Screening performance will be reduced when screening does not include all elements of the combined test

Contingent Screening in Limited Resource Settings

• Use maternal factors and MAP
• Consider reflex to PlGF and UTPI for those at increased risk a subgroup of the population

KEY POINTS:

FIGO Uses ISSHP Preeclampsia Definition

Systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women, with ≥1 of the following new‐onset conditions ≥20 weeks

• Proteinuria:
  • ≥30 mg/mol protein: Cr ratio | ≥300 mg/24 hour | ≥2 + dipstick
• Maternal organ dysfunction
  • Acute kidney injury: Creatinine ≥90 μmol/L; 1 mg/dL
  • Liver involvement: Elevated transaminases (e.g., alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain
  • Neurological complications: Eclampsia | Altered mental status | Blindness | Stroke | Clonus | Severe headaches | Persistent visual scotomata
  • Hematological complications: Thrombocytopenia (platelet count <150 000/μL) | DIC | Hemolysis
• Uteroplacental dysfunction
  • FGR
  • Abnormal umbilical artery Doppler
  • Stillbirth

How to Measure MAP

• Sitting position with arms at heart level, using appropriately sized cuff (after 5 minute rest)
  • Mid‐arm circumference: Small <22 cm | Normal 22–32 cm | Large 33–42 cm
• Measure BP in both arms simultaneously and
  • Two sets of BP measurements at 1 minute intervals
  • Total of 4 sets are used in the calculator

Prophylaxis for Women at High Risk

• Aspirin for prevention of preterm preeclampsia
  • Start between 11w0d to 14w6d
  • ~150 mg every night until
    • 36 weeks | Delivery | Preeclampsia diagnosed
  • Do not prescribe low-dose aspirin for all pregnant women
• Calcium
  • Low calcium intake (<800 mg/d)
    • Calcium replacement: ≤1 g elemental calcium/d or
    • Calcium supplementation: 1.5–2 g elemental calcium/d

Multiple Pregnancies

• Combined algorithm “can be adapted” for twins
  • High detection but also high screen-positive rate

ACOG and SMFM Guidance

• ACOG and SMFM have released guidance, stating that they “support the USPSTF guideline criteria for prevention of preeclampsia” on the use of low-dose aspirin during pregnancy to prevent preeclampsia (see ‘Related ObG Topics’ below)
• Offer low-dose aspirin (81 mg/day) to women with ≥1 high risk factors for preeclampsia
• Risk factors used for ACOG/SMFM recommendations only include factors obtained from the medical record
  • Uterine artery Doppler ultrasonography and biochemical markers are not included
• ACOG considers the supporting data for the use of such combined risk assessment algorithms to be limited and without more prospective clinical utility trials, states that

…biomarkers and ultrasonography cannot accurately predict preeclampsia and should remain investigational

Learn More – Primary Sources:

FIGO Releases New Guidelines to Combat Pre-Eclampsia

Risk Assessment Calculator of Preeclampsia

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

Related ObG Topics:

ASPRE Trial: A Combined Risk Algorithm and Use of Aspirin to Prevent Preterm Preeclampsia

ISUOG Recommendations for Preeclampsia Prevention: Combined Screening and the Role of Ultrasound

Aspirin Treatment for Women at Risk for Preeclampsia – ACOG and USPSTF Recommendations