Pre-eclampsia classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2]

Overview

In the new classification, proteinuria is not the main indicator for diagnosis of preeclampsia.The percentage of false-negative proteinuria, especially on the dipstick, is high. Preeclampsia may be classified according to the time of event into two groups: Early (preeclampsia before 34 weeks of gestation) and Late (preeclampsia after delivery). Preeclampsia with severe feature includes the following characteristics: systolic blood pressure ≥ 160 mmHg, diastolic blood pressure ≥ 110 mmHg, in two occasions apart 4 hours, thrombocytopnea (platelet count <100,000/dl), pulmonary edema, new-onset headache unresponsive to medications, visual disturbances, liver enzyme level > 2 times upper limit normal concentrations or persistent epigastric or right upper quadrant pain, and serum creatinine >1.1 mg/dl or doubling serum creatinine level in the absent of other causes of renal insufficiency.

Classification

• Preeclampsia may be classified according to presence of proteinuria into two groups:

• Preeclampsia with proteinuria
• Preeclampsia without proteinuria

• The percentage of false-negative proteinuria especially on the dipstick is high. It is not the main criteria for the diagnosis of preeclampsia.

• Preeclampsia may be classified according to the time of event into two groups:

• Early preeclampsia before 34 week of gestation
• Late preeclampsia after delivery

• Preeclampsia may be classified into:

• Preterm preeclampsia onset between 34 weeks and 1 day and 37 weeks
• Term preeclampsia onset after 37 weeks and 1 day

• Preeclampsia with severe feature includes the following characteristics:

• Systolic blood pressure≥ 160 mmHg,diastolic blood pressure≥ 110 mmHg, in two occasionS apart 4 hours
• Thrombocytopnea (platelet count <100,000/dl0
• Pulmonary edema
• New onset headache unresponsed to medications
• Visual disturbances
• Liver enzyme level > 2 times upper limit normal concentrations or persistent epigasteric or right upper quadrant pain
• Serum creatinin >1.1 mg/dl or doubling serum creatinine level in the absent of other causes of renal insufficiency

Abbreviations: ALT: alanine aminotransferase ; AST:Aspartate aminotransferase ;ISSHP:International Society for the Study of Hypertension in Pregnancy; ACOG:American College of Obstetricians and Gynecologists

ISSHP 2001/ACOG 2002	ISSHP 2018	ACOG 2013	ACOG 2018
❑ New onset of hypertension (blood pressure ≥140 mmHg systolic and/or ≥90 mmHg diastolic) after 20 weeks of gestation and ❑ proteinuria (urine protein/creatinine ≥30 mg/mmol (0.3 mg/mg)or ≥300 mg/day or at least (‘1+’) on dipstick testing	❑ New onset of hypertension (blood pressure of ≥140 mmHg systolic and/or ≥90 mmHg diastolic) after 20 weeks of gestation accompanied by one or more of the following: ❑ Proteinuria ❑ Maternal organ dysfunction including: ❑ Renal insufficiency (creatinine > 90 μmol/L; 1 mg/dL) ❑ Liver involvement (elevated transaminases with or without right upper quadrant or epigastric or abdominal pain) ❑ Neurological complications in eclampsia (altered mental status, blindness, stroke,hyperreflexia with clonus, severe headaches with hyperreflexia, persistent visual scotomata) ) ❑ Hematological complications (thrombocytopenia with platelet count below 150,000/dL, DIC, hemolysis	❑ New onset of hypertension (blood pressure of ≥140 mmHg systolic and/or ≥90 mmHg diastolic) after 20 weeks of gestation on two occasions at least 4 hours apart accompanied by one or more of the following: ❑ Proteinuria ❑ Maternal organ dysfunction including: ❑ Renal insufficiency (serum creatinine> 1.1 mg/dL) ❑ Impaired liver function (ALA or ASA ≥ 70 U/l) ❑ Cerebral or visual symptoms ❑ Thrombocytopenia (platelet count < 100,000/dL ❑ Pulmonary edema	❑ Systolic blood pressure of 140 mm Hg or more or diastolic blood pressure of 90 mm Hg or more on two occasions at least 4 hours apart after 20 weeks of gestation in a woman with a previously normal blood pressure ❑ Systolic blood pressure of 160 mm Hg or more or diastolic blood pressure of 110 mm Hg or more ❑ And ❑Proteinuria ❑ 300 mg or more per 24 hour urine collection ❑ Protein/creatinine ratio of 0.3 mg/dL or more or Dipstick of 2+ ❑ Or in the absence of proteinuria, new-onset hypertension with the new onset of any of the following: ❑ Thrombocytopenia (Platelet count less than 100,000/dl ❑ Renal insufficiency( Serum creatinine>1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease) ❑ Impaired liver function (Elevated blood level of liver transaminases to twice normal level) ❑ Pulmonary edema ❑ New-onset headache unresponsive to medication and not accounted for by alternative diagnoses or visual symptoms