Short- and long-term strategies for the management of hypertensive disorders of pregnancy. Evaluating glucose variability through OGTT in early pregnancy and its association with hypertensive disorders of pregnancy in non-diabetic pregnancies: a large-scale multi-center retrospective study. Received 2022 May 6; Accepted 2022 Jun 9. 55. Wang M., Chen S., He Y., Zhao M., Yang H., Chen Q. Low-dose aspirin for the prevention of severe preeclampsia in patients with chronic kidney disease: A retrospective study: This is the study for kidney and pregnancy. sharing sensitive information, make sure youre on a federal Licensee MDPI, Basel, Switzerland. National Library of Medicine The definition of FGR is also dynamic and may need to be raised when there is a flattening of the growth curve [38], to distinguish between low-birth-weight babies with harmonic growth, for genetic (or pathological) reasons, and babies whose normal growth was impaired at some point in their intrauterine life. Tranquilli AL, Brown MA, Zeeman GG, Dekker G, Sibai BM. Whelton P.K., Carey R.M., Aronow W.S., Casey D.E., Jr., Collins K.J., Dennison Himmelfarb C., DePalma S.M., Gidding S., Jamerson K.A., Jones D.W., et al. Wang W., Xie X., Yuan T., Wang Y., Zhao F., Zhou Z., Zhang H. Epidemiological trends of maternal hypertensive disorders of pregnancy at the global, regional, and national levels: A population-based study. 2021 Jun;24:96-99. doi: 10.1016/j.preghy.2021.03.002. Careers, Unable to load your collection due to an error. Moreover, except for the American College of Obstetrics and Gynecologists (ACOG), all other societies include signs of uteroplacental dysfunction, such as fetal growth restriction, an abnormal umbilical artery Doppler wave, and stillbirth as being diagnostic criteria of PE [7,8,9,10,12]. According to the same meta-analysis, chronic hypertension confers a relative risk of PE of up to 5.1 and, as is true for obesity, this is proportional to the severity of the baseline condition, followed by pre-existent diabetes (RR 3.7), autoimmune diseases, such as antiphospholipid syndrome (RR 2.8, 95% CI 1.84.3) and systemic lupus erythematosus (RR 1.8, 95% CI 1.52.1); the latter is estimated to have the same weight as CKD (RR 1.8, 95% CI 1.52.1), the risk of which varies according to the stage [19]. Prevention of preeclampsia. Inclusion in an NLM database does not imply endorsement of, or agreement with, Other new features of the definition of PE are laboratory findings regarding liver involvement, with an increase in aminotransferases (alanine aminotransferase and/or aspartate aminotransferase at >40 IU/L, whether or not this is accompanied by right-upper quadrant or epigastric abdominal pain), thrombocytopenia (platelets at <109/L), disseminated intravascular coagulation (DIC), and hemolysis. Alexopoulos A.S., Blair R., Peters A.L. Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Gaber T.Z., Shemies R.S., Baiomy A.A., Aladle D.A., Mosbah A., Abdel-Hady E.S., Sayed-Ahmed N., Sobh M. Acute kidney injury during pregnancy and puerperium: An Egyptian hospital-based study. and transmitted securely. c Queensland risk factors (no distinction between high or moderate risk): personal or family history of preeclampsia, multiple pregnancy (increased risk with multiples), nulliparity, pregestational BMI > 35 kg/m2, age > 40, SBP > 130 mmHg or DBP > 80 mmHg at initial visit, inter-pregnancy interval >10 years, renal disease, pre-existing diabetes, chronic autoimmune disease, chronic hypertension, antiphospholipid antibodies. Dietary management before and during pregnancy should be considered in both overweight and underweight patients, as well as screening for vitamin status, in particular for the vitamin D axis, which appears to be related to PE onset [56,88,89]. ), 5Department of Obstetrics and Gynaecology, Ospedale Degli Infermi, 13875 Biella, Italy; ti.oohay@76363tsamb, 6Unit of Nephrology, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, 80138 Naples, Italy, 7Nephrology, Azienda Ospedaliera Brotzu, 09047 Cagliari, Italy; moc.liamg@acnarfnaiguddibac, 8Department of Clinical and Biological Sciences, University of Torino, 10064 Torino, Italy; ti.otinu@onisrev.attebasile, 9University Centre of Biostatistics, Epidemiology and Public Health, University of Torino, 10064 Torino, Italy. The .gov means its official. ), fetoplacental system (abnormal fetal heart rate, oligohydramnios, stillbirth, etc. As for nephrology guidelines, in 2017, those of the Italian Society of Nephrology included a best-practice statement for the prevention and follow-up of PE [45]. Lees C.C., Stampalija T., Baschat A., da Silva Costa F., Ferrazzi E., Figueras F., Hecher K., Kingdom J., Poon L.C., Salomon L.J., et al. In fact, as reported in a classic study on a large cohort, conducted by Hernandez Diaz and co-workers in Sweden in 2009, the risk of PE was found to be 4.1% in first pregnancies, while the incidence of PE was 1.7% in the subsequent gestations of patients without a history of PE, and PE in the first pregnancy was associated with a 14.7% risk of its recurrence in the second gestation and a risk of up to 31.9% after two PE episodes [75]. PE, preeclampsia; HTA, hypertension; SBP, systolic blood pressure; DBP, diastolic blood pressure; SGA, small for gestational age; CKD, chronic kidney disease. The second element of interest is that being born small for gestational age and/or with a low birth weight is, in turn, associated with the risk of developing CKD, hypertension, diabetes, and metabolic syndrome in adulthood and, for females, with developing preeclampsia once pregnant, thus generating a vicious circle of diseases reappearing over generations, not necessarily with a genetic basis [47,48,49,50]. Tranquilli AL, Brown MA, Zeeman GG, Dekker G, Sibai BM. 2023 Apr 25;14:1140020. doi: 10.3389/fphar.2023.1140020. Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice Hypertension. Postnatal assessment for renal dysfunction in women with hypertensive disorders of pregnancy: A prospective observational study. The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014. Careers. Cabiddu G., Longhitano E., Cataldo E., Lepori N., Chatrenet A., Torreggiani M., Attini R., Masturzo B., Rossini M., Versino E., et al. OBrien T.E., Ray J.G., Chan W.S. Indications for starting antihypertensive medication in pregnancy, and blood pressure goals in the hypertensive disorders of pregnancy in national and international guidelines. Is It Possible to Differentiate Chronic Kidney Disease and Preeclampsia by means of New and Old Biomarkers? Interestingly, apart from having experienced a hypertensive disorder and/or placental dysfunction during pregnancy, a familial history of PE in a first-degree relative represented a significant risk factor (RR 2.90, 95% CI 1.704.93) [19]. HHS Vulnerability Disclosure, Help While this may be difficult to put into practice, given a lack of dedicated resources, the expert agreement reported in the best practice holds that a woman should be monitored by a nephrologist for at least 6 months after a PE episode (monthly, until the normalization of proteinuria and hypertension, and at least once for 2 to 3 months afterward) to identify unresolved hypertension, kidney function impairment or persistent proteinuria. Covella B., Vinturache A.E., Cabiddu G., Attini R., Gesualdo L., Versino E., Piccoli G.B. T hese recommendations from the International Society for the Study of Hypertension in Pregnancy (ISSHP) are based on available literature and expert opinion. Bethesda, MD 20894, Web Policies Sibai B.M., Mercer B., Sarinoglu C. Severe preeclampsia in the second trimester: Recurrence risk and long-term prognosis. A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre-eclampsia: Compiled by the Pregnancy and Non-Communicable Diseases Committee of FIGO (the International Federation of Gynecology and Obstetrics). The site is secure. sharing sensitive information, make sure youre on a federal 2018 Jan;11:142-144. doi: 10.1016/j.preghy.2017.09.006. Vikse B.E., Irgens L.M., Bostad L., Iversen B.M. Self-monitoring of blood pressure, possibly integrated as needed with 24-h blood pressure measurement, is part of the management recommended for women classified as being at high risk of PE. The .gov means its official. Disclaimer. Adding creatinine to routine pregnancy tests: A decision tree for calculating the cost of identifying patients with CKD in pregnancy. Over 30% of these fetuses were SGA, often without a causal diagnosis [44]. Identification and correction, where possible, of the risk factors for both these disorders and for potential future health problems, early counseling, and long-term nephrological follow-up could help improve the management of the health of women and their offspring. Comparing standard office-based follow-up with text-based remote monitoring in the management of postpartum hypertension: a randomised clinical trial. Legend: ACOG (American College of Obstetricians and Gynecologists), ACC/AHA (American College of Cardiology/American Heart Association), Brazil (Brazilian Guideline of Arterial Hypertension), DGGG (Deutsche Gesellschaft fr Gynkologie und Geburtshilfe), ESC/ESH (European Society of Cardiology/European Society of Hypertension), FIGO (The International Federation of Gynecology and Obstetrics), Hypertension Canada, NICE (National Institute for Health and Care Excellence), Ireland (Royal College of Physicians of Ireland), SOMANZ (Society of Obstetric Medicine of Australia and New Zealand), Queensland (Queensland Clinical Guideline), USPSTF (US Preventive Services Task Force), WHO (World Health Organization). Maternal kidney function during pregnancy: Systematic review and meta-analysis. Timofeeva AV, Fedorov IS, Sukhova YV, Ivanets TY, Sukhikh GT. 2023 Apr 28;24(9):8006. doi: 10.3390/ijms24098006. JAAPA. and transmitted securely. a, Manhattan plot of the 13 loci associated with preeclampsia/eclampsia in 20,064 individuals and 703,117 healthy controls.b, Manhattan plot of the 7 loci associated with gestational hypertension . Maayeh M., Costantine M.M. eCollection 2023. International Society for the Study of Hypertension in Pregnancy (ISSHP). Pregnancy Hypertens. 1Nphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; ti.orebil@onatihgnol.asile (E.L.); moc.liamg@otagilisallessor (R.S. 2023 Apr 18;13(8):1457. doi: 10.3390/diagnostics13081457. As a library, NLM provides access to scientific literature. Comparing early PE (<28 weeks) to PE at 2833 weeks, the first group was found to be more likely to deliver preterm (38.8% and 28.7%, respectively) and to experience perinatal death (4.3% vs. 1.2%) during a subsequent gestation [76]. Pregnancy Hypertens, (1):44-47 2012 MED: 26105740 . A long-standing misconception is that PE more frequently, or even almost exclusively, affects first pregnancies. Rolnik D.L., Wright D., Poon L.C., OGorman N., Syngelaki A., de Paco Matallana C., Akolekar R., Cicero S., Janga D., Singh M., et al. ES-1. [(accessed on 27 April 2022)]. INFANT Centre, Federal government websites often end in .gov or .mil. Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (, proteinuria 0.3 g/24h or PCR 0.3 g/g or dipstick 2+, headache with visual symptoms or unresponsive to medications, White-coat HTN: detection at office/clinic of BP 140/90 mmHg, but normal domiciliary blood pressure (<135/85 mmHg). Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice Authors: Mark A Brown UNSW Sydney Laura Magee King's College. The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice (Pregnancy Hypertension, 2018), Argentine Society of Hypertension: Pregnancy and kidney disease. Epub 2012 Jun 12. FOIA Severe, very early onset preeclampsia: Subsequent pregnancies and future parental cardiovascular health. Currently, there are two different approaches: one that considers HELLP syndrome a severe variant of PE (Figure 3), and one that sees it as a distinct disease, while acknowledging that there is a shared pathogenesis and risk factors as well as an interplay between all these disorders [34]. By joining us, you will be entitled to a number of benefits. Ibarra-Hernandez M., Orozco-Guillen O.A., de la Alcantar-Vallin M.L., Garrido-Roldan R., Jimenez-Alvarado M.P., Castro K.B., Villa-Villagrana F., Borbolla M., Gallardo-Gaona J.M., Garcia-Garcia G., et al. Cabiddu G., Mannucci C., Fois A., Maxia S., Chatrenet A., Osadolor S., Kimani E., Torreggiani M., Attini R., Masturzo B., et al. Federal government websites often end in .gov or .mil. Including these conditions increases the number of cases that, at least according to the Italian Society of Nephrology (to date, the only group to have published a specific statement on follow-up after preeclampsia), should undergo a basic nephrology evaluation to exclude the presence of CKD [45]. According to the ASPRE trial, in fact, women taking low-dose ASA during their pregnancies had a 0.38 odds ratio of experiencing PE compared to controls [95]. Features of preeclampsia, according to international guidelines. An official website of the United States government. In this scenario, FGR, newborns that are small for gestational age, and intrauterine death, are part of the spectrum of the hypertensive disorders of pregnancy; while they can occur in association with hypertension or full-blown PE, they may also be isolated and without other PE features [7,8,9,10,11,12]. g Moderate risk factors (ACOG): nulliparity, obesity (BMI > 30 kg/m2), family history of preeclampsia (mother or sisters), African-American ethnicity, low socioeconomic status, age > 35, history of a neonate that is small for gestational age, previous adverse pregnancy outcome, or an inter-pregnancy interval of >10 years. A Prospective Study. a The BUMP 1 trial aimed to establish whether self-monitoring blood pressure with telemonitoring in addition to usual care could lead to earlier detection of elevated clinic blood pressure, compared with usual care, during higher-risk pregnancies. Authors Prediction and prevention of recurrent preeclampsia. PMC Several issues are not yet clear: the blood pressure target is still a matter of discussion and, while reaching lower targets was not associated with an improvement in maternal and fetal health, the presence of known chronic kidney disease (CKD) is acknowledged as a reason for trying to reach lower BP targets (Table 2). The International Society for the Study of Hypertension in Pregnancy: Low-dose acetylsalicylate (ASA) is considered to be the most promising drug for reducing the risk of PE and FGR, as well as preterm birth and perinatal mortality in women classified as being at high risk of PE [92,93,94]. Current state of affairs: A study regarding diagnosis, treatment and use of home blood pressure monitoring for hypertension in pregnancy. eCollection 2023. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Before Tangren J.S., Powe C.E., Ankers E., Ecker J., Bramham K., Hladunewich M.A., Karumanchi S.A., Thadhani R. Pregnancy Outcomes after Clinical Recovery from AKI. Authors The hypertensive disorders of pregnancy (HDP) are no longer seen as transitory diseases cured by delivery, but as windows into the future that allow us to predict a womans future cardiovascular and kidney health. Gaugler-Senden I.P., Berends A.L., de Groot C.J., Steegers E.A. Of note, the baseline CKD risk is probably significant, as shown by the different risk curves observed in Norway (low incidence of CKD) and Taiwan (high incidence of CKD) [69]. Zhao R., Zhou L., Wang S., Xiong G., Hao L. Association between maternal vitamin D levels and risk of adverse pregnancy outcomes: A systematic review and dose-response meta-analysis. The hypertensive disorders of pregnancy, in particular PE and HELLP, can further exert a negative effect on kidney health via the development of AKI; once more, the baseline renal conditions matter, and especially in developing countries, the difference between AKI and AKI associated with CKD may be difficult to distinguish, but it is relevant to the future of renal function, i.e., 729% of the women needing dialysis in pregnancy fail to fully recover [71,72,73,74]. Prevalence of preeclampsia and eclampsia in adolescent pregnancy: A systematic review and meta-analysis of 291,247 adolescents worldwide since 1969. This site needs JavaScript to work properly. 2001;20(1):IX-XIV. Giannakou K., Evangelou E., Papatheodorou S.I. The authors declare no conflict of interest. Along with hemolysis, thrombocytopenia, and liver impairment, other typical features are hypertension, present in 8288% of pregnant women, and proteinuria, which is found in 86100% of pregnant women, according to the cohorts evaluated [52]. The elements defining high-risk and moderate-risk factors for PE in the different guidelines are summarized in Table 4. It is also suggested that if recurrent or severe PE occurs in a woman with acknowledged risk factors, she should be referred to a tertiary care center in the case of subsequent gestation [45]. rtqvist AK, Magnus MC, Dahlqvist E, Sderling J, Johansson K, Sandstrm A, Hberg SE, Stephansson O. BMJ Med. Published in Hypertension and Pregnancy Hypertension These recommendations from the International Society for the Study of Hypertension in Pregnancy (ISSHP) are based on available literature and expert opinion. Cork University Maternity Hospital, Poon L.C., Magee L.A., Verlohren S., Shennan A., von Dadelszen P., Sheiner E., Hadar E., Visser G., Da Silva Costa F., Kapur A., et al. HHS Vulnerability Disclosure, Help Research on the hypertensive disorders of pregnancy over the past 20 years has led to the recognition of these ailments as possible signs of an underlying disease and as precursors of future health problems involving the kidney. Unauthorized use of these marks is strictly prohibited. Proteinuria levels 0.3 g/24 h or a protein-to-creatinine ratio (PCR) 0.3 g/g is present in about 75% of the cases defined as PE. 2019 May;37(2):301-316. doi: 10.1016/j.emc.2019.01.008. b SOMANZ risk factors (no distinction between high or moderate risk): personal or family history of preeclampsia, nulliparity, multiple pregnancy, BMI 25 kg/m2, age 40, SBP > 130 mmHg or DBP > 80 mmHg before 20 gestational weeks, antiphospholipid syndrome, renal disease, pre-existing diabetes, chronic autoimmune disease, inter-pregnancy interval >10 years. Available online: Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Once more, this choice reflects the view that all HDPs are interlinked, even though they do not necessarily occur with the same severity (Figure 2). Accessibility The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice, Guidelines for the diagnosis, study, treatment and monitoring of Hypertension, The Classification and Diagnosis of the Hypertensive Disorders of Pregnancy, The Classification, Diagnosis and management of the Hypertensive Disorders of Pregnancy: A revised statement from the ISSHP, Statements fromthe International Society for the Study of Hypertension in Pregnancy, The Management of severe pre-eclampsia/eclampsia, Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy, The management of servere pre-eclampsia/eclampsia, Diagnosis, evaluation and management of the hypertensive disorders of pregnancy, Copyright 2021 ISSHP - All Rights Reserved. Dong X., Han M., Zeb S., Tong M., Li X., Chen Q. In addition, these guidelines specify that an SGA fetus may be small but not at increased risk of adverse perinatal outcomes, while a fetus with a size above the 10th percentile may still be considered FGR and at increased risk of adverse perinatal and long-term outcomes [39]. In this regard, the new guidelines underline the central role of kidney involvement, basing a diagnosis not only on proteinuria but also on a reduction in kidney function from the baseline pre-gestational level [7,8,9,10,11,12]. Wilton, ; writingreview and editing, E.L., R.S., M.T. US Preventive Services Task Force. The phenotype of PE also seems to modulate the risk of recurrence and, according to the same study, the risk of recurrence was much higher in early-onset PE (up to 60% in a second pregnancy and up to 90% after two early PE episodes) [75]. 2023 May 22;16:1493-1503. doi: 10.2147/DMSO.S410912. Preeclampsia and ESRD: The Role of Shared Risk Factors. American College of Obstetricians and Gynecologists Low-dose aspirin use during pregnancy. Other anomalies are non-uniformly aggregated in this family of diseases; this is the case for isolated or pregnancy-induced proteinuria (in normotensive pregnancies) and fetal growth restriction (FGR), which have, however, been demonstrated to predict the risk of developing PE during gestation as well as the risk of adverse short- and long-term maternal-fetal outcomes, including the development of chronic kidney disease (CKD). Prospective longitudinal studies with large cohorts are necessary to support the key role of the kidney, and clearly define the need for clinical evaluation by a nephrologist during and after an episode of a hypertensive disorder in pregnancy. No such data are available for pregnancy. Considering that FGR can also be the result of fetal diseases, a genetic evaluation should be proposed by the obstetric team, in cases of early recognition (<32 gestational weeks) or when in association with polyhydramnios or, more obviously, of fetal malformations [38]. Serum Creatinine Levels Before, During, and After Pregnancy. About 50% of patients with gestational hypertension continue to have high BP levels after delivery. Diagnosis of placental insufficiency independently of clinical presentations using sFlt-1/PLGF ratio, including SGA patients. The Management of Hypertension in Pregnancy. 743. Management of thrombotic microangiopathy in pregnancy and postpartum: Report from an international working group. Expert Rev Cardiovasc Ther. Please enable it to take advantage of the complete set of features! Adverse perinatal outcome and later kidney biopsy in the mother. Pregnancy Hypertens. Innes K.E., Marshall J.A., Byers T.E., Calonge N. A womans own birth weight and gestational age predict her later risk of developing preeclampsia, a precursor of chronic disease. While, in the past, proteinuria was required for a PE diagnosis, international boards now consider it to be of the same importance as other symptoms and signs [7,8,9,10,11,12]. The incidence of hypertensive disorders during pregnancy has increased in the last three decades, reaching 18,080,000 cases/year (a 10.92% increase), with a higher rate in South Asia and sub-Saharan Africa, in contrast to Australasia, Oceania, and Central Europe, where the lowest incidence is found, according to Wang and his colleagues in their population-based study [3]. WHO Recommendations for Prevention and Treatment of Pre-Eclampsia and Eclampsia. (2001). THE CLASSIFICATION AND DIAGNOSIS OF THE HYPERTENSIVE DISORDERS OF PREGNANCY: STATEMENT FROM THE INTERNATIONAL SOCIETY FOR THE STUDY OF HYPERTENSION IN PREGNANCY (ISSHP) Mark A. Statements from the International Society for the Study of Hypertension in Pregnancy (ISSHP). ix-xiv. Crossref Medline Google Scholar; 3. Piccoli G.B., Torreggiani M., Crochette R., Cabiddu G., Masturzo B., Attini R., Versino E., Pregnancy Study Group of the Italian Society of Nephrology What a paediatric nephrologist should know about preeclampsia and why it matters. government site. Definitions of the hypertensive disorders of pregnancy, as found in the national and international guidelines. 1, pp. Khosla K., Heimberger S., Nieman K.M., Tung A., Shahul S., Staff A.C., Rana S. Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: Recent Advances in Hypertension. Symptoms reported by patients range from severe headaches, persistent visual scotomata, or blindness to alterations in mental state and complications such as clonus, eclampsia, and stroke. Morgaan HA, Sallam MY, El-Gowelli HM, El-Gowilly SM, El-Mas MM. Rolfo A., Attini R., Tavassoli E., Neve F.V., Nigra M., Cicilano M., Nuzzo A.M., Giuffrida D., Biolcati M., Nichelatti M., et al. Epub 2018 May 24. Montersino B., Menato G., Colla L., Masturzo B., Piccoli G.B., Attini R. A young woman with proteinuria and hypertension in pregnancy: Is what looks and smells like preeclampsia always preeclampsia? ; writingoriginal draft preparation, E.L., R.S. Chronic kidney disease in preeclamptic patients: Not found unless searched for-Is a nephrology evaluation useful after an episode of preeclampsia? Cabiddu G., Castellino S., Gernone G., Santoro D., Moroni G., Giannattasio M., Gregorini G., Giacchino F., Attini R., Loi V., et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. The women who experience these disorders have a greater risk of having or developing kidney diseases than women with normotensive pregnancies. Katsi V., Skalis G., Vamvakou G., Tousoulis D., Makris T. Postpartum Hypertension. The https:// ensures that you are connecting to the Gjerde A., Reisaeter A.V., Skrunes R., Marti H.P., Vikse B.E. A feasibility study. Epub 2017 Sep 12. PMC Wiles K., Bramham K., Seed P.T., Nelson-Piercy C., Lightstone L., Chappell L.C. However, since serum creatinine assessment is not part of the work-up of physiological pregnancies, the interpretation of a serum creatinine level that is still in the normal range in pregnancy may be difficult, if not impossible. Although this interpretation is not universally accepted, it offers a change in perspective, making it possible for us to see the hypertensive disorders of pregnancy not only as transient alterations due to gestation but also as endothelial disorders that may recur in subsequent pregnancies or evolve into long term endothelial dysfunction and, in turn, CKD. 2018 Jul;13:291-310. doi: 10.1016/j.preghy.2018.05.004. International Society for the Study of Hypertension in Pregnancy (ISSHP). . The definition of HDP encompasses a spectrum of conditions that extends from gestational hypertension to preeclampsia (PE), eclampsia, and to hemolysis, elevated liver enzymes, and low platelet-count syndrome (HELLP). Conversely, advanced maternal age has a modest effect on PE (3540 years old, RR 1.2, 95% CI 1.11.3; 40 years old, RR 1.5, 95% CI 1.22.0) [19]. The sequential hypothesis of a continuum of severity of the hypertensive disorders of pregnancy. The highest risk of all adverse pregnancy outcomes (including low birth weight, preterm delivery, and PE) recorded in younger age groups is influenced by several factors associated with teenage pregnancy, including low educational level, low income, malnutrition, precarious health before gestation, and marital status, factors that also reflect a continued lack of concern for young womens health [4,5]. 2009 Dec;7(12):1581-94. doi: 10.1586/erc.09.147. government site. Unable to load your collection due to an error, Unable to load your delegates due to an error. 2018; 72: 24-43. . In order to accomplish our task, we reviewed the available guidelines and the relevant literature. 2023 May 9;24(10):8496. doi: 10.3390/ijms24108496. Institute of Obstetricians and Gynaecologists. The issue is similar to those problems that may arise in attempting to control diabetes, where hypercorrection and frequent hypoglycemia can have negative effects on pregnancy outcomes [25]. The definition of HDP has changed considerably over time; it is only recently that the principal obstetrical and gynecological international boards have agreed on diagnostic criteria, the main features of which are summarized in Table 1 [7,8,9,10,11,12]. The definitions of the hypertensive disorders of pregnancy have changed greatly in recent years. Disclaimer. 2012 Nov;30(4):903-17. doi: 10.1016/j.emc.2012.08.006. The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice Authors: Mark A Brown UNSW Sydney Laura Magee King's College. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Gestational or pregnancy-induced hypertension, which affects up to 10% of pregnant women, is recognized by all societies as new-onset blood pressure (BP) 140/90 mmHg at or after 20 gestational weeks. The Classification and Diagnosis of the Hypertensive Disorders of Pregnancy: Statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP) Hypertension in Pregnancy: Vol. However, the data on the risk of recurrence varies widely: a population-based record-linkage cohort study in Australia found much lower cumulative rates of recurrence of PE in the subsequent pregnancy after a first early PE episode. Barrett P.M., McCarthy F.P., Kublickiene K., Cormican S., Judge C., Evans M., Kublickas M., Perry I.J., Stenvinkel P., Khashan A.S. The position of the HELLP syndrome in the context of the hypertensive disorders of pregnancy is still debated, although this severe condition is currently included in most guidelines regarding HDP [7,8,9,10,11,12]. and E.V. Optimism bias in understanding neonatal prognoses. Accordingly, the quality of evidence for the recommendations in this document has not been graded, though relevant references and explanations are provided 2018 Jul;13:291-310. doi: 10.1016/j.preghy.2018.05.004. Macedo T.C.C., Montagna E., Trevisan C.M., Zaia V., de Oliveira R., Barbosa C.P., Lagana A.S., Bianco B. and G.B.P. Ananth C.V., Duzyj C.M., Yadava S., Schwebel M., Tita A.T.N., Joseph K.S. 7th Brazilian Guideline of Arterial Hypertension: Chapter 9Arterial Hypertension in pregnancy. Hypertens Res. other maternal organ dysfunction, including: liver involvement (ALT or AST > 40 IU/L) with or without right upper quadrant or epigastric abdominal pain, neurological complications (eclampsia, altered mental status, blindness, stroke, clonus, severe headache, persistent visual scotomata), hematological complications (thrombocytopenia, DIC, hemolysis), uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth), Masked HTN: normal at a clinic or office measurement, elevated at other times, and diagnosed by 24 h ABPM or HBPM. BMJ Qual Saf. Unauthorized use of these marks is strictly prohibited. Brown, M. A. et al. Townsend R., Khalil A., Premakumar Y., Allotey J., Snell K.I.E., Chan C., Chappell L.C., Hooper R., Green M., Mol B.W., et al. The different conditions will be discussed in detail in the pages that follow. The classification and diagnosis of the hypertensive disorders of pregnancy: statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP) Hypertens Pregnancy . Among the numerous subsequent studies on this important issue, the recent large population study by Gjerde and co-workers deserves mention: considering over two million individuals, after a mean follow-up period of 26 years, low birth weight was associated with an odds ratio of 1.72 for CKD, 1.79 for SGA, and 1.48 for preterm birth (95% CI, 1.33 to 1.66) [51]. The hypertensive disorders of pregnancy have been related to defective placentation, which may be severe enough to impair the physiologic development of the fetus during pregnancy. Harel Z., McArthur E., Hladunewich M., Dirk J.S., Wald R., Garg A.X., Ray J.G. While none of these has proved to be sufficient to clearly distinguish between phenotypes and, above all, to be invariably correlated with maternal-fetal short- and long-term outcomes, these approaches are the basis of a better description of the phenotype of PE, which, albeit with wide overlaps, can enable clinicians to perform a prognostic evaluation of individual cases. We are delighted to announce the publication of: Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice. Royal College of Obstetricians and Gynaecologists Late Intrauterine Fetal Death and Stillbirth. Given the prognostic role that angiogenic markers play in evaluation of patients with "suspected preeclampsia," the International Society for the Study of Hypertension in Pregnancy incorporated angiogenic imbalance into the 2021 definition of preeclampsia. The management of hypertension in pregnancy. Poniedzialek-Czajkowska E., Mierzynski R. Could Vitamin D Be Effective in Prevention of Preeclampsia? Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy (2008), The Royal College of Obstetricians and Gynaecologists (RCOG). MeSH A randomized trial of ambulatory blood pressure monitoring versus clinical blood pressure measurement in the management of hypertension in pregnancy. Epidemiology and Mechanisms of De Novo and Persistent Hypertension in the Postpartum Period. Zhou Q., Chen W.Q., Xie X.S., Xiang S.L., Yang H., Chen J.H. Bethesda, MD 20894, Web Policies Proposed classifications of PE according to severity, time of onset, and pathogenesis. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. This information may help clinicians in the management of pregnancy, prolonging gestation in the case of CKD, or intensifying care or anticipating the delivery in the presence of preeclampsia. Gulati M. Early Identification of Pregnant Women at Risk for Preeclampsia: USPSTF Recommendations on Screening for Preeclampsia. The relevance for nephrologists of the inclusion of FGR in the context of the hypertensive disorders of pregnancy is high. Legend: ACOG, American College of Obstetricians and Gynecologists; ACC/AHA, American College of Cardiology/American Heart Association; DGGG, Deutsche Gesellschaft fr Gynkologie und Geburtshilfe; ESC/ESH, European Society of Cardiology/European Society of Hypertension; FIGO, The International Federation of Gynecology and Obstetrics; ISSHP, International Society for the Study of Hypertension in Pregnancy; NICE, National Institute for Health and Care Excellence; Ireland, SOMANZ, Society of Obstetric Medicine of Australia and New Zealand; Queensland, Queensland Clinical Guideline. Future interaction among International Society of Hypertension (ISH), Japan Society of Hypertension (JSH) and ISSHP. Filali Khattabi Z., Biolcati M., Fois A., Chatrenet A., Laroche D., Attini R., Cheve M.T., Piccoli G.B. Prakash J., Pant P., Prakash S., Sivasankar M., Vohra R., Doley P.K., Pandey L.K., Singh U. Management of Preexisting Diabetes in Pregnancy: A Review. All authors have read and agreed to the published version of the manuscript. A large meta-analysis evaluating trials with at least 20 preeclampsia patients, with a follow-up of 4 years, involving 110,803 PE cases and 2,680,929 controls, quantified the OR of developing ESRD after preeclampsia at 6.35; however, it also suggested a knowledge gap regarding the intermediate phases of CKD, thus indicating the need for prospective follow-up after PE, to better clarify the natural history of CKD after PE [68]. and G.B.P. When setting BP goals in pregnancy, we should keep in mind that outside the context of pregnancy, the results for CKD patients under tight hypertension control in the recent ACCORD BP trial demonstrated that the benefits obtained in reducing cardiovascular events and mortality were offset by a higher risk of adverse kidney outcomes, which are mainly represented by AKI [26]. Indications for the administration of acetylsalicylic acid (ASA) in preeclampsia prevention, as found in national and international guidelines. Williams B., Mancia G., Spiering W., Agabiti Rosei E., Azizi M., Burnier M., Clement D.L., Coca A., de Simone G., Dominiczak A., et al. The Classification and Diagnosis of the Hypertensive Disorders of Pregnancy (2001), The Classification, Diagnosis and management of the Hypertensive Disorders of Pregnancy: A revised statement from the ISSHP(2014), The denition of severe and early-onset preeclampsia (ISSHP): 2012 Aug;30(3):407-23. doi: 10.1016/j.ccl.2012.04.005. Acute kidney injury in pregnancy and the role of underlying CKD: A point of view from Mexico. Tano S, Kotani T, Ushida T, Yoshihara M, Imai K, Nakamura N, Iitani Y, Moriyama Y, Emoto R, Kato S, Yoshida S, Yamashita M, Kishigami Y, Oguchi H, Matsui S, Kajiyama H. Diabetol Metab Syndr. Chronic hypertension and pregnancy outcomes: Systematic review and meta-analysis. Clipboard, Search History, and several other advanced features are temporarily unavailable. Preeclampsia is a valuable opportunity to diagnose chronic kidney disease: A multicentre study. PS-1. Statements fromthe International Society for the Study of Hypertension in Pregnancy (2013), The Royal College of Obstetricians and Gynaecologists (RCOG) This paradigm shift has led to an increased need for integrated care for women who experience a hypertensive disorder during pregnancy, involving specialists that can oversee and coordinate treatment, and, whenever possible, work to identify risk factors and correct them [1,2]. Emerg Med Clin North Am. Van Rijn B.B., Hoeks L.B., Bots M.L., Franx A., Bruinse H.W. T12 YE02. official website and that any information you provide is encrypted eCollection 2023. Wang I.K., Muo C.H., Chang Y.C., Liang C.C., Chang C.T., Lin S.Y., Yen T.H., Chuang F.R., Chen P.C., Huang C.C., et al. The authors matched 79,334 women with preg-HTN to 396,531 normotensive women. The site is secure. Hypertension 65(1), 54-61 . Hypertension in pregnancy may be chronic (predating pregnancy or diagnosed before 20 weeks of pregnancy) or de novo (either preeclampsia or gestational hypertension). The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guidelines distinguish between FGR and SGA, as follows: FGR is defined as the fetus failing to reach its genetically predetermined growth potential, while SGA is diagnosed when the fetus size falls below a predefined threshold for its gestational age (usually the 10th percentile) [39]. Moreover, the best way to manage patients after an episode of pregnancy-related AKI remains undefined [1,34,70]. Position paper Hypertension in Pregnancy(2010), The International Society for the Study of Hypertension in Pregnancy: Epub 2018 Apr 27. Please enable it to take advantage of the complete set of features! While a discussion of the cardiovascular effects of PE is beyond the scope of this review, its effects on kidney function deserve mention. Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. ), CNS (eclampsia, PRES, cortical blindness, Glasgow coma scale 13, stroke, TIA, or RIND), cardiorespiratory (uncontrolled severe HTN over 12 h, oxygen saturation <90%, pulmonary edema, positive inotropic support, or myocardial ischemia or infarction), renal (AKI or new indication for dialysis), hepatic (INR.2 in the absence of DIC or warfarin), fetoplacental system (abruption with evidence of maternal or fetal compromise, reverse ductus venosus A wave, or stillbirth), one or more adverse conditions (e.g., PE), one or more severe complications (e.g., PE), hematologic (thrombocytopenia, hemolysis, DIC), hepatic (raised ALT and AST, epigastric or right upper quadrant pain), CNS (eclampsia, hyperreflexia with sustained clonus, persistent headache, visual disturbances, PRES, stroke), SBP > 130 mmHg or DBP > 80 mmHg before 20 gestational weeks, SBP > 130 mmHg or DBP > 80 mmHg at initial visit, family history of preeclampsia (mother or sisters), hypertensive disease during a previous pregnancy, pregnancy, chronic kidney disease, preeclampsia, small for gestational age, hypertension. A recent meta-analysis of 92 studies, involving 25,356,688 gestations, identified further maternal predisposing conditions for the onset of PE [19]. The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. d High risk factors (NICE, ESC/ESH, Royal College of Physicians of Ireland): a hypertensive disorder during a previous pregnancy, chronic kidney disease, autoimmune disease, pre-existing diabetes, chronic hypertension. Reddy M., Fenn S., Rolnik D.L., Mol B.W., da Silva Costa F., Wallace E.M., Palmer K.R. Would you like email updates of new search results? Legend: ACOG, American College of Obstetricians and Gynecologists; ESC/ESH, European Society of Cardiology/European Society of Hypertension; ISSHP, International Society for the Study of Hypertension in Pregnancy; NICE, National Institute for Health and Care Excellence; SOMANZ, Society of Obstetric Medicine of Australia and New Zealand; Queensland, Queensland Clinical Guideline; WHO, World Health Organization. Lowe S.A., Bowyer L., Lust K., McMahon L.P., Morton M., North R.A., Paech M., Said J.M. Publishers Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. and transmitted securely. Moreover, we should consider that renal damage may be induced by causes other than the hypertensive disorders of pregnancy, such as hypovolemia, ischemia (e.g., severe postpartum hemorrhage), or sepsis, which can cause acute tubular necrosis or cortical necrosis with adverse outcomes for maternal renal function, both immediately and in the long term [34,59]. Previous preeclampsia and risk for progression of biopsy-verified kidney disease to end-stage renal disease. The hypothesis of distinct disorders that may merge into one another. Gestational hypertension. FGR is defined by the fetal weight, or an abdominal circumference estimated using ultrasounds, showing growth between the 3rd and 10th percentile for gestational age (moderate fetal growth restriction) or less than the 3rd percentile (the severe form) [38]. Preeclamptic programming unevenly perturbs inflammatory and renal vasodilatory outcomes of endotoxemia in rat offspring: modulation by losartan and pioglitazone. Brown M.A., Magee L.A., Kenny L.C., Karumanchi S.A., McCarthy F.P., Saito S., Hall D.R., Warren C.E., Adoyi G., Ishaku S., et al. Lopes van Balen V.A., van Gansewinkel T.A.G., de Haas S., Spaan J.J., Ghossein-Doha C., van Kuijk S.M.J., van Drongelen J., Cornelis T., Spaanderman M.E.A. The Society of Obstetricians and Gynaecologists of Canada (SOGC) and the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) also include cardiac and/or pulmonary involvement in the diagnostic criteria for PE [7,8,9,10,11,12]. The ISSPHs 2018 guidelines highlighted that among the signs included for the diagnosis of PE, FGR, thrombocytopenia, proteinuria, AKI, or liver impairment had the strongest association with the risks of severe adverse maternal-fetal outcomes [33]. Clipboard, Search History, and several other advanced features are temporarily unavailable. The hypertensive disorders of pregnancy (HDP) are no longer seen as "transitory diseases cured by delivery", but as windows into the future that allow us to predict a woman's future cardiovascular and kidney health. ISUOG Practice Guidelines: Diagnosis and management of small-for-gestational-age fetus and fetal growth restriction. While the correction of pre-gestational BMI and other potentially reversible predisposing factors has not been demonstrated to completely offset the increased risk of PE recurrence, it appears to mitigate the risk of adverse pregnancy-related events [56]. 2023 May 24;2(1):e000465. In these cases, the consensus statement holds that women should be monitored according to local indications for CKD, while yearly follow-ups should be offered to other women, especially those who express the wish for a new pregnancy. PE is a multisystem disease, generally defined as a condition in which the onset of arterial hypertension after 20 weeks of gestation is accompanied by at least one sign of renal, hepatic, central nervous system, or hematologic impairment [7,8,9,10,11,12] (Figure 1). These include babies that are small for gestational age (SGA), intrauterine growth restriction (IUGR) or its synonymous fetal growth restriction (FGR), and an increased risk of pre-term delivery, which is usually classified as very early pre-term (<28 gestational weeks), early pre-term (2834 weeks or, presently, more often, 2832 gestational weeks) and late pre-term (according to the previous definitions: 3237 or 3437 gestational weeks), or intrauterine death [7,8,9,10,11,12]. Hypertension in pregnancy may be chronic (predat-ing pregnancy or diagnosed before 20 weeks of preg-nancy) or de novo (either preeclampsia or gestational hypertension). The https:// ensures that you are connecting to the Martino, University of Messina, 98125 Messina, Italy; ti.eminu@orotnas.ocinemod, 3Unit of Nephrology, Azienda Ospedaliera Universitaria SantAnna, 44124 Ferrara, Italy, 4Department of Obstetrics and Gynecology, Citt della Salute e della Scienza, Ospedale SantAnna, University of Torino, 10126 Torino, Italy; moc.liamg@initta.allessor (R.A.); ti.ilacsit@alusac.aloiv (V.C. This acknowledgment of the high heterogeneity of PE, in parallel with the proposal to unify the pathogenesis of PE and other hypertensive disorders of pregnancy, has led to an attempt to stratify PE, based on a variety of elements from severity to the period of onset and pathogenic mechanisms (Table 3) [34]. Gkiougki E., Chatziioannidis I., Pouliakis A., Iacovidou N. Periviable birth: A review of ethical considerations. The objective of this article is to briefly review their main definitions and epidemiology as a support for nephrologists, who are increasingly involved in the management of HDP in the short and long term. Kattah A.G., Scantlebury D.C., Agarwal S., Mielke M.M., Rocca W.A., Weaver A.L., Vaughan L.E., Miller V.M., Weissgerber T.L., White W., et al. This site needs JavaScript to work properly. Before 2023 Jun 9;15(1):123. doi: 10.1186/s13098-023-01103-z. Methods: We circulated a questionnaire to the International Committee of the International Society for the Study of Hypertension in Pregnancy focusing on the thresholds for defining severe preeclampsia and the gestation at which to define early-onset preeclampsia, and on the definition and inclusion of the HELLP syndrome or other clinical . Once more, nephrologists often have a different view of the situation, as is suggested by the best-practice guidelines of the Italian Society of Nephrology, which, while acknowledging the risks of hypotension in pregnancy, recommend the correction of hypertension, as in the case of young patients outside the context of pregnancy (target BP 130/80 mmHg), under strict clinical surveillance [24]. Nayak B., Moon J.Y., Kim M., Fischhoff B., Haward M.F. Accessibility After Viskes pivotal study on the Norway registry, highlighting the risk of end-stage kidney disease after PE (an OR of about 4.7), attention has increasingly been focused on these issues: subsequent studies showed a close association between an episode of PE and the need for a kidney biopsy later in life, suggesting that hypertensive disorder may be either a trigger for or an early marker of renal dysfunction [60,66,67]. Association between hypertensive disorders during pregnancy and end-stage renal disease: A population-based study. Blood pressure targets and kidney and cardiovascular disease: Same data but discordant guidelines. Conversely, an interesting unifying approach includes HELLP syndrome, together with pregnancy-induced thrombotic microangiopathies (TMAs), mainly because they share patterns of endothelial cell injury (primarily affecting the kidneys and the cardiovascular and central nervous systems, with a hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, and catastrophic antiphospholipid syndrome) [53]. The .gov means its official. However, the physiological reduction in serum creatinine during physiological pregnancies should be considered. The American Heart Association (AHA) has included a history of PE or gestational hypertension as a major risk factor for cardiovascular disease since 2011 [85,86] and, in a 2017 meta-analysis, Wu and colleagues confirmed that PE was independently associated with an increased risk of future heart failure (RR 4.19), coronary heart disease (RR 2.50), global cardiovascular disease-related death (RR 2.21), and stroke (RR 1.81) [87]. 015/018, December 2013). FOIA Fakhouri F., Scully M., Provot F., Blasco M., Coppo P., Noris M., Paizis K., Kavanagh D., Pene F., Quezada S., et al. 2018 Jul;72(1):24-43.doi: 10.1161/HYPERTENSIONAHA.117.10803. Maternal body mass index and the risk of preeclampsia: A systematic overview. Classification. Outcomes of subsequent pregnancy after first pregnancy with early-onset preeclampsia. In this regard, the more extensive PE definition merges with the definition of HELLP syndrome, indirectly alluding to a univocal definition of HDPs. HHS Vulnerability Disclosure, Help Before Similarly, starting from the 20th to the 24th week, frequent checking of the proteinuria/creatinuria ratio on spot urine (for instance, every 12 weeks, according to clinical condition) can allow the early identification of incipient proteinuria; monitoring the sFLT1/PIGF ratio, starting at the 20th week, can make it possible to have the elements available to anticipate placental distress [90]. Modified from [34]. Smith P., Abdelmaguid A., Clark K., Bramham K. Lessons for the clinical nephrologist: Recurrent pregnancy-associated thrombotic microangiopathy (TMA) with a known complement mutation and features of preeclampsia; a diagnostic and therapeutic dilemma. An ISSHP membership makes you part of a global community of researchers who are determined to reduce the impact hypertensive disorders have on mothers and babies. Despite the fact that the relationship between low birth weight and prematurity and subsequent disorders during pregnancy has been described for decades, the message that the risk of preeclampsia in the mother decreases with increased gestational age has not been fully integrated into clinical practice, and no specific surveillance programs have been set up for such high-risk pregnancies (the odds ratio (OR) of developing PE was about 4 for mothers born earlier than 34 gestational weeks, and is even higher for those born under 4.5 lb, about 2 kg) [47]. Intrauterine death is distinguished from miscarriage, which is defined as fetal loss before 20 gestational weeks in the United States, while the British guidelines still set the cut-off point at 24 weeks, which was previously the agreed point. doi: 10.1136/bmjmed-2022-000465. Magee L.A., Khalil A., Kametas N., von Dadelszen P. Toward personalized management of chronic hypertension in pregnancy. 2014; 4:97-104. doi: 10.1016/j.preghy.2014.02.001. The revised classication for hypertensive disorders inpregnancy is as follows (Table 1): Chronic hypertension. Society for Maternal-Fetal Medicine. Other smaller cohort studies report a variable recurrence rate of preeclampsia, ranging from 25 to 65% [77,78,79,80]. Overall, 33.8% of women who experienced an episode of early PE during the first pregnancy developed PE in a subsequent singleton pregnancy [76]. Preeclampsia and Future Cardiovascular Health: A Systematic Review and Meta-Analysis. Hypertension in Pregnancy compared with studies in essential hy-pertension outside of pregnancy and ISSHP encourages greater funding and uptake of collaborative research in this eld. Low birth weight, nephron number, and kidney disease. Risk of Preeclampsia and Adverse Pregnancy Outcomes after Heterologous Egg Donation: Hypothesizing a Role for Kidney Function and Comorbidity. Laboratory findings, including peripheral thrombocytopenia, mechanical hemolytic anemia (defined by hemoglobin levels of 10 g/dL, lactate dehydrogenase (LDH) at the upper limit of normal, undetectable haptoglobin, and the presence of schistocytes on the blood smear), as well as signs of impaired organ function, such as a rise in serum creatinine or transaminases, can be present in PE and HELLP as well as in TMAs [53]. ISSHP charged a small group of clinician researchers toprovide recommendations about the appropriate classi-cation, denitions, and management of the hypertensivedisorders of pregnancy. Fetoplacental system ( abnormal fetal heart rate, oligohydramnios, stillbirth, etc Skalis G., Vamvakou G., G.. Long-Standing misconception is that PE more frequently, or even almost exclusively, affects first pregnancies M.! Toprovide recommendations about the appropriate classi-cation, denitions, and management of hypertensive disorders of pregnancy have greatly! 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