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Croatian society for perinatal medicine: Consensus statement and recommendations for the risk assessment of preeclampsia

Open AccessPublished:August 08, 2021DOI:https://doi.org/10.1016/j.ejogrb.2021.08.003

      Abbreviations:

      FGR (fetal growth restriction), FMF (Fetal Medicine Foundation), PlGF (placental growth factor), sFlt-1 (soluble fms-like tyrosine kinase-1)
      Dear Editor,
      In the Croatian healthcare system, a gynaecologist is required to manage all pregnant women. We are reporting our guidelines for screening pregnant women who are at risk of developing preeclampsia. These have been developed by the Croatian Society for Perinatal Medicine [

      Croatian Society for Perinatal Medicine. Available from: http://www.hdpm.hr/. Accessed: May 2021.

      ] and should be implemented in the outpatient and inpatient settings, as summarised in Fig. 1. These guidelines have been published by the society in Gynaecologia et Perinatologia [
      • Đelmiš J.
      • Habek D.
      • Ivanišević M.
      • Košec V.
      • Muller A.
      • Petrović O.
      • et al.
      Risk assessment for preeclampsia.
      ].
      Figure thumbnail gr1
      Fig. 1Guidelines for risk assessment of preeclampsia for the second and third trimesters (20–34 weeks of gestation) using the Elecsys® sFlt-1/PlGF test (Roche Diagnostics). Figure reproduced from Đelmiš et al. 2019 (2).
      Preeclampsia is a common cause of maternal and perinatal morbidity and mortality, especially when it occurs early in pregnancy [
      • Poon L.C.
      • Shennan A.
      • Hyett J.A.
      • Kapur A.
      • Hadar E.
      • Divakar H.
      • et al.
      The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: a pragmatic guide for first-trimester screening and prevention.
      ]. Identifying women at high risk of developing preeclampsia in the first trimester of pregnancy is crucial for early implementation of necessary measures to improve placentation and prevent disease, or at least reduce its frequency [
      • Poon L.C.
      • Shennan A.
      • Hyett J.A.
      • Kapur A.
      • Hadar E.
      • Divakar H.
      • et al.
      The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: a pragmatic guide for first-trimester screening and prevention.
      ].
      Preeclampsia is defined by a systolic blood pressure of ≥ 140 mmHg (≥160 mmHg for severe preeclampsia) and/or diastolic blood pressure of ≥ 90 mmHg (≥110 mmHg for severe preeclampsia), measured at least twice in a timeframe of 4 h apart in previously normotensive pregnant women, and the presence of proteinuria (≥0.3 g in a 24-hour period urine sample) [
      • Poon L.C.
      • Shennan A.
      • Hyett J.A.
      • Kapur A.
      • Hadar E.
      • Divakar H.
      • et al.
      The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: a pragmatic guide for first-trimester screening and prevention.
      ,
      • Scott G.
      • Gillon T.E.
      • Pels A.
      • von Dadelszen P.
      • Magee L.A.
      Guidelines-similarities and dissimilarities: a systematic review of international clinical practice guidelines for pregnancy hypertension.
      ]. Additional clinical features of severe preeclampsia include oliguria (<500 mL in 24 h), severe headache or impaired vision, epigastric pain, pulmonary oedema or cyanosis, thrombocytopenia, creatinine ≥ 90 μmol/L, transaminases > 40 IU/L, disseminated intravascular coagulation, and fetal growth restriction (FGR) [
      • Poon L.C.
      • Shennan A.
      • Hyett J.A.
      • Kapur A.
      • Hadar E.
      • Divakar H.
      • et al.
      The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: a pragmatic guide for first-trimester screening and prevention.
      ,
      • Wagner L.K.
      Diagnosis and management of preeclampsia.
      ].

      Risk assessment guidelines for the first/second trimester of pregnancy

      Risk assessment for the development of preeclampsia, between 11 and 14 weeks of pregnancy, is recommended if the patient has one high or two moderate risk factors.
      High risk factors:
      • Hypertensive disease during previous pregnancy and associated complications (HELLP [haemolysis, elevated liver enzymes, and a low platelet count] syndrome, placental abruption, FGR, stillbirth)
      • Chronic hypertension
      • Chronic kidney disease
      • Autoimmune diseases such as systemic lupus erythematosus
      • Acquired thrombophilia (antiphospholipid syndrome). If the patient is diagnosed with this syndrome the suggested therapy includes aspirin and heparin
      • Hereditary thrombophilia (mutation of the prothrombin or factor V gene, deficiency of antithrombin, protein C and protein S)
      • Type 1 and type 2 diabetes
      Moderate risk factors:
      • First pregnancy
      • Pregnant age > 40 years
      • Time interval between two pregnancies > 10 years
      • Body mass index > 35 kg/m2
      • Gestational diabetes
      • Family history of preeclampsia
      • Twin pregnancy
      • Pregnancy after in vitro fertilisation
      The risk assessment includes a family, personal and obstetric history, physical exam (age, body height, body mass, body mass index, blood pressure, mean arterial pressure), pulsatile index of the uterine artery, and a biomarker placenta growth factor (PlGF) test.
      The values are entered into the Fetal Medicine Foundation (FMF) algorithm (or any other accredited preeclampsia risk assessment algorithm) to assess the risk of developing preeclampsia (https://fetalmedicine.org/research/assess/preeclampsia/first-trimester). If the risk is ≥ 1:100, the introduction of prophylactic aspirin therapy by a specialist in fetal and maternal medicine should be considered.

      Risk assessment guidelines for the second/third trimester of pregnancy

      After 20 weeks of pregnancy, use of the soluble fms-like tyrosine kinase-1 (sFlt-1)/PlGF ratio is recommended, which, in addition to clinical evaluation, may help predict or exclude the risk of developing preeclampsia (Fig. 1). Threshold values for sFlt-1/PlGF are between 38 and 85 (for 20–34 weeks of gestation) and 38–110 (for > 34 weeks of gestation), with values > 85 or > 110 indicating an increased risk of developing early or late onset preeclampsia within 4 weeks, respectively.
      These are among the first guidelines which include the use of biomarkers as a major component in risk assessment across all trimesters of pregnancy to aid in diagnosis and rule in/out of preeclampsia. Following these guidelines is vital for effective monitoring and treatment of pregnant women to avoid disease progression.

      Declaration of interest

      All authors received an honorarium from Roche Diagnostics for participating in an advisory board for preeclampsia testing.

      Funding

      Funding for this advisory board and letter was provided by Roche Diagnostics. Medical writing assistance was provided by Katie Farrant, Elements Communications Ltd, Westerham, UK.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Acknowledgements

      We would like to express our gratitude to the Croatian Society for Perinatal Medicine (https://www.hdpm.hr/) and the society’s journal Gyneaceologia et Perinatologia (https://gynaecolperinatol.hr/en/home/) for their support with developing these guidelines. ELECSYS is a trademark of Roche.

      References

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