Pregnancy Hypertension 19 (2020) 206–211

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Pregnancy Hypertension
journal homepage: www.elsevier.com/locate/preghy

Evaluation of the clinical impact of the revised ISSHP and ACOG definitions T
on preeclampsia
⁎
Anisha R. Bouter, Johannes J. Duvekot
Department of Obstetrics and Gynecology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands

A R T I C LE I N FO A B S T R A C T

Keywords: Background: In 2018/2013 both ISSHP and ACOG revised their original statements and postulated new criteria
Preeclampsia for preeclampsia with and without severe features. Most importantly, preeclampsia can now also be established
Proteinuria in the absence of proteinuria when other specific symptoms are present.
Criteria Objective: What is the clinical impact of the use of three different new definitions for the diagnosis of pre-
Definitions
eclampsia?
Study design: Retrospective cohort study of all pregnant women who gave birth in the Erasmus MC between 01
and 01-2014 and 01-01-2016. Hypertensive disorders of pregnancy (HDP) were defined when blood pressure
was elevated at least during two occasions. All HDP cases were classified according to the ISSHP 2001, ISSHP
2018 and ACOG 2013 definitions.
Results: In our cohort (N = 4395) 878 patients had HDP (20,0%). The ISSHP 2018/ACOG 2013 definition cause
a significant increase in patients with (superimposed) preeclampsia versus the ISSHP 2001 definition, from 272
patients (6,2%) to respectively 360 (8,2%)/290 (6,6%) (p < 0,001/p < 0,001). This increase is due to non-
proteinuric preeclampsia cases. According to the ACOG 2013 definition there were 154 (53,1%) cases of pre-
eclampsia with severe features. Neonatal NICU admission rates were almost doubled in the proteinuric pre-
eclampsia group compared to the non-proteinuric preeclampsia group.
Discussion: Implementation of the ISSHP 2018/ACOG 2013 definitions cause a shift from gestational hy-
pertension and chronic hypertension towards (superimposed) preeclampsia (relative increase 10%/2%). These
increases are caused by inclusion of non-proteinuric cases. More research is necessary into the course and
prognosis of especially non-proteinuric preeclampsia cases.

1. Introduction superimposed preeclampsia or gestational hypertension [3]. For women

Preeclampsia (PE) is a hypertensive disorder during pregnancy
complicating 3–8% of all pregnancies and may lead to health risks for
both mother and fetus [1]. The precise etiology is yet unknown, but it
seems that it is caused by reduced placental perfusion and impaired
remodelling of the spiral arteries [2]. Preeclampsia may lead to head-
aches, visual impairments, IUGR, uteroplacental insufficiency, fetal
asphyxia and death, maternal seizures and even maternal death. Other
hypertensive disorders of pregnancy (HDP) are gestational hyperten-
sion, superimposed preeclampsia and chronic hypertension.
Management of HDP in the Netherlands follows national and in-
ternational guidelines. Since the only current effective treatment for
HDP remains delivery, induction of labor is recommended for
women < 24 weeks and > 37 weeks of gestation with preeclampsia,
with gestational age between 24 and 37 weeks, expectant management
may be considered, but there is no evidence this is without an increase
in maternal risks. Only for cases between 34 and 37 weeks without
severe features it was shown that expectant management does not in-
crease maternal risks [4]. In our country, women with preeclampsia are
admitted to a hospital from the moment of diagnosis until delivery. For
chronic hypertension, expectant management is recommended
throughout the whole pregnancy in case blood pressure remains stable.
For cases of preeclampsia with severe features, it is recommended to
induce labor before the 24th week or after the 34th week of gestation
[5,6]. To make optimal clinical decisions in these circumstances un-
ambiguously HDP definitions are mandatory.
Several societies use different definitions for the diagnosis of hy-
pertensive disorders in pregnancy. Also, these definitions are regularly

⁎
Corresponding author at: Department of Obstetrics and Gynecology, Erasmus Medical Center Rotterdam, Wytemaweg 80, PO Box 2040, 3000 CA Rotterdam, the
Netherlands.
E-mail address: j.j.duvekot@erasmusmc.nl (J.J. Duvekot).

https://doi.org/10.1016/j.preghy.2019.11.011
Received 10 August 2019; Received in revised form 3 November 2019; Accepted 25 November 2019
Available online 11 December 2019
2210-7789/ © 2019 Published by Elsevier B.V. on behalf of International Society for the Study of Hypertension in Pregnancy.
A.R. Bouter and J.J. Duvekot Pregnancy Hypertension 19 (2020) 206–211

Table 1
ISSHP 2001, ISSHP 2018, ACOG 2002 and ACOG 2013 definitions for preeclampsia.
ISSHP 2001/ACOG 2002 ISSHP 2018 ACOG 2013

New onset of hypertension (blood pressure of
≥140 mmHg systolic and/or ≥90 mmHg
diastolic) after 20 weeks of gestation and
proteinuria (spot urine protein/creatinine
≥30 mg/mmol [0.3 mg/mg]a or
≥300 mg/day or at least [‘1+’] on dipstick
testingb)
New onset of hypertension New onset of hypertension (blood pressure of ≥140 mmHg
(blood pressure of ≥140 mmHg systolic and/or ≥90 mmHg systolic and/or ≥90 mmHg diastolic) after 20 weeks of
diastolic) after 20 weeks of gestation accompanied by one or gestation on two occasions at least 4 h apart accompanied by
more of the following new-onset conditions at or after one or more of the following:1. Proteinuria2. Maternal organ
20 weeks’ gestation: dysfunction including:
1. Proteinuria
2. Maternal organ dysfunction, including:
• Renal insufficiency (serum creatinine
concentrations ≥ 100 μmol/L; 1.1 mg/dL)
• Renal insufficiency (creatinine > 90 μmol/L; 1 mg/dL) • Impaired liver function (ALAT or ASAT ≥ 70 U/l)
• Liver involvement (elevated transaminases with or • Cerebral or visual symptoms
without right upper quadrant or epigastric abdominal • Thrombocytopenia (platelet count < 100,00/dL
pain) • Pulmonary edema
• Neurological complications (examples include
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)
3. Uteroplacental dysfunction (such as fetal growth
restriction, abnormal umbilical artery Doppler wave)

ISSHP 2001, ISSHP 2018, ACOG 2002 and ACOG 2013 definitions for preeclampsia

Table 2 2. Methods
ISSHP 2018 and ACOG 2013 definitions for preeclampsia with severe features.
ISSHP 2018 ACOG 2013
2.1. Study design

No definition Severe features of preeclampsia: A retrospective case-control study design using electronic patient
•Blood pressure of ≥ 160 mmHg systolic and/or ≥ 110 mmHg
diastolic on two occasions at least 4 h apart
files was conducted in the Erasmus University Medical Centre, depart-

•Thrombocytopenia (platelet count < 100,00/dL

ment of Obstetrics. All women who gave birth in the Erasmus MC be-
•Impaired liver function (ALAT or ASAT ≥ 70 U/l) tween January 1st, 2014 and December 31th, 2015, with at least once
•Progressive renal insufficiency (serum
creatinine ≥ 100 μmol/L; 1.1 mg/dL)
measured hypertension during their pregnancy, defined as
≥140 mmHg systolic and/or ≥90 mmHg diastolic, were eligible for
•Pulmonary edema
•
inclusion in the study. Exclusion criteria were: < 2 available blood
New onset cerebral or visual symptoms
pressure measurements during pregnancy, blood pressure elevated only
ISSHP 2018 and ACOG 2013 definitions for preeclampsia with severe features. on one occasion during pregnancy, women who did not give birth in the
Erasmus MC, and incomplete patient files or data. Blood pressures were
updated and changed. The diagnosis of preeclampsia used to rely on the measured with an aneroid device after ten minutes of rest and with an
presence of hypertension and proteinuria. In 2013 and 2014 however, appropriate cuff size.
the International Society for the Study of Hypertension in Pregnancy This study was approved by the Institutional Review Board of the
(ISSHP) and the American College of Obstetricians and Gynecologists Erasmus Medical Centre.
(ACOG) revised their definitions and stated that the diagnosis pre-
eclampsia can be established in the absence of proteinuria when other
2.2.
specific symptoms are present [7,8]. In 2018 the ISSHP updated their
definitions on preeclampsia, but stated the same diagnostic criteria as in
Hypertension was defined as ≥140 mmHg systolic and/or
2014 [9] (Table 1). The change in definitions was due to the recogni-
≥90 mmHg diastolic and severe hypertension as ≥160 mmHg systolic
tion of maternal and fetal risk in non-proteinuric preeclampsia, which is
and/or ≥110 mmHg diastolic. Proteinuria was defined as spot urine
suggested to be a different phenotype of preeclampsia rather than a
protein/creatinine ≥30 mg/mmol [0.3 mg/mg] or 24 h urine
different disease. Also, there is a high percentage of false negative
≥300 mg/day or at least 1 g/L [‘2+’] on dipstick testing according to
proteinuria test results, especially when dipstick testing is used. For the
the ISSHP 2018definition and at least [‘1+’] on dipstick testing ac-
diagnosis of preeclampsia with severe features, only the ACOG has a
cording to the ISSHP 2001, ACOG 2002 and ACOG 2013 definition.
definition. (Table 2). In the most recent statements of both ACOG and
Severe proteinuria was defined as ≥5000 mg/day in 24 h urine or at
ISSHP the use of the term severe preeclampsia is discarded. Classifi-
least [‘3+’] on dipstick testing. Fetal growth restriction was present
cation of preeclampsia as mild or severe could be misleading, because
when the patient was diagnosed with IUGR according to their electronic
the clinical condition may deteriorate rapidly. Therefore, the ISSHP
patient file, or when the Estimated Fetal Weight (EFW) was < p10,
advises not to use the term severe preeclampsia in clinical practice. The
using Astraia software.
ACOG instead rephrased it into preeclampsia with severe features.
To define organ failure the cut off values of the ISSHP and ACOG
Still there is no consensus on which definition should be used for
statements were used. Liver involvement was defined as ASAT or
preeclampsia. Since the clinical management of hypertensive disorders
ALAT ≥ 70 U/l and/or right upper quadrant or epigastric abdominal
of pregnancy differ, use of different definitions may have consequences.
pain. Neurological complications include eclampsia, altered mental
Therefore, we evaluated the clinical impact of the use of the ‘old’ ISSHP
status, blindness, stroke, hyperreflexia with clonus, severe headache
2001/ACOG 2002 definitions versus the ‘new’ ISSHP 2018 and ACOG
with hyperreflexia or persistent visual scotomata reported in the pa-
2013 definitions. Also, we compared the short-term pregnancy out-
tients file. Renal insufficiency was defined as creatinine > 90 μmol/L
comes of patients with proteinuric and non-proteinuric preeclampsia.
according to the ISSHP 2018 definition and as creatinine > 100 μmol/L
according to the ACOG 2013 definition. Hematological complications
were defined as thrombocytopenia with platelet count < 150,000/dL

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and/or DIC and/or hemolysis according to the ISSHP 2018 definition

and as thrombocytopenia with platelet count < 100,000/dL according
to the ACOG 2013 definition.
The following short-term pregnancy outcomes were defined. As
neonatal complications, preterm birth before 32 weeks and low birth-
weight, defined as a birth weight of < 1250 g, were chosen. Maternal
complications included thrombo-embolic complications, solutio pla-
centae, pneumonia, lung edema, eclampsia, fluxus postpartum and
maternal death.
Only prepartum and peripartum measurements were reported.
Postpartum diagnoses were not included in this study.

2.3. Data collection

Through research of electronic patient files data was collected on

blood pressure, proteinuria, fetal growth restriction (FGR), renal in-
sufficiency, live involvement, neurological complications, hematolo-
gical complications and short-term pregnancy complications being
prematurity, NICU admission, low birth weight, maternal complications
and perinatal death. Thereafter we evaluated all included patients and
based on the measurements above, the patients were retrospectively
diagnosed using the different definitions for hypertensive pregnancy
disorders, independent of the diagnosis they received at the time.

2.4. Statistical analysis

All statistical analyses were performed using Statistical Package for

the Social Sciences (SPSS program version 21; IBM Corp.). To address
our primary objective, the McNemar’s test for paired nominal data was
used to compare the number of patients in all hypertensive disorder
groups, comparing two groups at a time. Continuity correction was
performed if there was a 0 in one of the columns and binomial dis-
tribution was applied if the numbers in certain columns were below the
limit.
To address our secondary objective, short-term pregnancy compli-
cations were compared between proteinuric preeclampsia and non-
Fig. 1. Flowchart.
proteinuric preeclampsia groups. The level of statistical significance
was established at p < 0,05.
4.2. Superimposed preeclampsia

3. Results
Four thousand and three hundred ninety-five women gave birth in
the Erasmus MC between 1 January 2014 and 31 December 2015, of
which 1835 women met the inclusion criteria for this study. After data
collection, 874 women had elevated blood pressure on only one occa-
sion during pregnancy, 81 women had incomplete patient files and two
women did not give birth in the Erasmus MC and were excluded.
Eventually 878 women had hypertensive disorders of pregnancy and
were included in the study, as shown in the flowchart (Fig. 1).
With the ISSHP 2001/ACOG 2002 definition 54 women (6,2%) were
retrospectively diagnoses with superimposed preeclampsia, whereas 67
women (7,6%) were diagnosed using the ISSHP 2018 criteria and 57
patients (6,5%) using the ACOG 2013 definition. The difference in
number of women with superimposed preeclampsia is only statistically
significant when the ISSHP 2001 and ISSHP 2018 definitions are
compared (p < 0,001) and when the ACOG 2013 and ISSHP 2018
definitions are compared (p = 0,025) (Table 3).
4.3. Preeclampsia with severe features

4. Primary outcome
4.1. Preeclampsia
In the cohort of 4395 patients, 878 women (20%) had HDPs. Of
them, 218 patients (24,8%) were retrospectively diagnosed with pre-
eclampsia using the ISSHP 2001/ACOG 2002 definition, 293 women
(33,4%) using the ISSHP 2018 definition and 233 patients (26,5%)
using the ACOG 2013 definition. All differences are statistically sig-
nificant (p < 0,001) as shown in Table 3. Compared to the ISSHP
2001/ACOG 2002 definition, the ISSHP 2018 and ACOG 2013 defini-
tions cause an increase in the incidence of preeclampsia from 6,2% to
respectively 8,2% and 6,6% (Table 4).
According to the ACOG 2013 definition there were 154 (53,1%)
cases of preeclampsia with severe features (Table 5).
Fig. 2 shows the number of patients with PE and superimposed PE
according to the different definitions.
The increase in number of patients with preeclampsia is due to non-
proteinuric cases. Table 6 shows that in these cases women are diag-
nosed as preeclampsia mostly due to the addition of FGR and haema-
tological complications in the ISSHP 2018 criteria. For the ACOG 2013
criteria the increase is mostly caused by haematological complications
and liver involvement, since FGR is not included (Table 7).

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Table 3
Distribution of the hypertensive disorders using ISSHP 2001, ISSHP 2018 and ACOG 2013 criteria.
ISSHP 2001/ACOG 2002 ISSHP 2018 ACOG 2013 P-value

All hypertensive disorders N = 878 N = 878 N = 878

Gestational Hypertension, n. (%) 519 (59,1%) 443 (50,5%) 503 (57,3%) P < 0,001a *
P < 0,001b *
P < 0,001c *
Preeclampsia, n. (%) 218(24,8%) 293 (33,4%) 233 (26,5%) P < 0,001a *
P < 0,001b *
P < 0,001c *
Chronic hypertension with superimposed preeclampsia, n. (%) 54 (6,2%) 67 (7,6%) 57 (6,5%) P < 0,001a *
P = 0,25b
P = 0,002c *
Chronic Hypertension, n. (%) 87 (9,9%) 75 (8,5%) 85 (9,7%) P = 0,002a *
P = 0,625b
P = 0,002c *

Distribution of the hypertensive disorders using ISSHP 2001, ISSHP 2018 and ACOG 2013 criteria.
*p < 0,05.
a
ISSHP2001 compared to ISSHP 2018.
b
ISSHP 2001 compared to ACOG 2013.
c
ISSHP 2018 compared to ACOG 2013.

5. Secondary outcome Table 5

Cases of preeclampsia with severe features and
Table 8 shows that preterm birth, perinatal death, low birth weight weeks of gestation at birth.
and maternal complications were not statistically different in preg- ACOG 2013
nancies complicated by non-proteinuric preeclampsia compared to N = 154
proteinuric preeclampsia. There were less NICU admissions in the non-
< 32 weeks 72 (47%)
proteinuric preeclampsia diagnosed with the ISSHP 2018 definition
32–34 weeks 14 (9%)
(p = 0,019, p = 0,011). The number of short-term pregnancy com- 34–37 weeks 27 (17%)
plications was too small to perform a multiple logistic regression ana- > 37 weeks 41 (27%)
lysis.
Cases of preeclampsia with severe features and
weeks of gestation at birth.
6. Discussion

Implementation of the ISSHP 2018/ACOG 2013 definition causes a

shift from gestational hypertension and chronic hypertension towards
preeclampsia and superimposed preeclampsia (relative increase 10%/
2%). This shift is due to non-proteinuric preeclampsia cases. The
number of short-term pregnancy complications did not differ between
the proteinuric and non-proteinuric cases.
To evaluate if our findings could be confirmed, we searched for
other studies with a similar research question. One study from J. Kallela
et al. was found, in which the researchers only found minor changes in
number of preeclampsia when applying the ‘new’ ISSHP and ACOG
criteria [5]. The increase of the preeclampsia cases was 0.8% (1459/
1447) according to the ACOG 2013 criteria and 0.6% (1455/1447)
according to the ISSHP 2018 criteria. However, cases were re-evaluated
based on the diagnosis the included women got at time of admission.
Also, there was only a small number of gestational hypertension and
chronic hypertension cases, whilst the number of preeclamptic cases Fig. 2. Preeclampsia and chronic hypertension with superimposed pre-
was very high which might have biased the effect. eclampsia.

6.1. Impact on clinical management of HDP the ‘new’ definitions used to be diagnosed as pregnancy induced hy-
pertension or chronic hypertension according to the ‘old’ definitions.
The shift in diagnoses due to the use of different definitions has Since the preeclampsia guidelines advise admission in case of pre-
clinical impact. Women with non-proteinuric preeclampsia according to eclampsia, this would lead to an increase in number of women admitted

Table 4
(Superimposed) preeclampsia and preeclampsia with severe features.
ISSHP 2001 ACOG 2002 ISSHP 2018 ACOG 2013

Total preeclampsia * n. (% of all pregnancy’s) 272 (6,2%) 272 (6,2%) 360 (8,2%) 290 (6,6%)
Preeclampsia with severe features, n. (% of total preeclampsia) – 161 (59,2%) – 154 (53,1%)

(Superimposed) preeclampsia and preeclampsia with severe features.

*Preeclampsia + chronic hypertension with superimposed preeclampsia.

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Table 6
Causes of the shift in diagnoses using the ISSHP 2018 criteria.
Preeclampsia ISSHP 2018 Superimposed preeclampsia ISSHP 2018 Total preeclampsia** ISSHP 2018

Only caused by FGR 28 (37,3%) 6 (46,2%) 34 (38,6%)

Only caused by maternal organ dysfunction without proteinuria * 44 (58,7%) 6 (46,2%) 50 (56,8%)
Renal insufficiency** 9 (20,5%) 1 (16,7%) 10 (20,0%)
Liver involvement** 7 (15,9%) 2 (33,3%) 9 (18,0%)
Neurological complications** – – –
Hematological complications** 37 (84,1%) 5 (83,3%) 42 (84,0%)
Caused by FGR + Maternal organ dysfunction 3 (4,0%) 1 (7,7%) 4 (4,5%)
Total 75 13 88

Causes of the shift in diagnoses using the ISSHP 2018 criteria.

*Used ISSHP 2018 cut off values as shown in Table 1.
**% of only caused by maternal organ failure.
***Preeclampsia + chronic hypertension with superimposed preeclampsia.

to the hospital, especially between 24 and 37 weeks of gestation.
We found that, of the women who were diagnosed as chronic hy-
pertension according to the ‘old’ definitions, 13 women (increase of
24%, using ISSHP 2018) and 3 women (increase of 5%, ACOG 2013)
would be diagnosed as superimposed preeclampsia according to the
‘new’ definitions. For women with chronic hypertension and stable
blood pressure, expectant management is recommended, whereas for
superimposed preeclampsia induction of labor is recommended after
37 weeks. This would cause an increase in induction of labor in the
group of non-proteinuric superimposed preeclampsia. Probably this
prevents deterioration of the clinical situation.
The ACOG 2013 definition for preeclampsia with severe features
includes severe hypertension and/or organ failure. As a result, we found
154 cases of preeclampsia with severe features using the ACOG 2013
definition. Of these 154 cases, 17,5% gave birth between 34 and
37 weeks of gestation. For women with preeclampsia with severe fea-
tures, in our department it is recommended to induce labor from
34 weeks of gestation onwards, whilst for preeclampsia without severe
features this is recommended from 37 weeks onwards. Use of the ACOG
2013 criteria therefore may also lead to an increase in inductions of
labor between 34 and 37 weeks of gestation due to preeclampsia with
severe features. ISSHP recommends induction of labor in cases of pre-
eclampsia with severe features without stating from which gestational
age onwards.
6.2. Strengths and limitations
One of the strengths of this study is the volume and completeness of
the cohort, since all women who gave birth in our hospital over a period
of two years were screened for inclusion. Futhermore, of all these
women blood pressure was measured and electronically recorded. All
patient files were individually screened, and patient were retro-
spectively diagnosed according to all the different definitions, so the
data was not effected by the diagnoses that was given at the time.
The major limitation of this study is the retrospective study design.
Some electronic patient files had missing data, and, in some cases,
certain lab values had not been requested because at that time the
ISSHP 2001 criteria were used in the Erasmus MC. Therefore, the
number of non-proteinuric preeclampsia cases might even have been
underestimated. Also, postpartum preeclampsia could not be included
because postpartum data were not available. However, our aim was to
evaluate the clinical impact and effect on antepartum management and
timing of delivery. Due to the retrospective design we were unable to
perform correction for the effect of white coat hypertension.
Normotensive preeclampsia was disregarded since the ISSHP and ACOG
did not mention this in their latest statements.
An important note is that for the women included in this study
policy decisions and timing of delivery was still based on the ‘old’ de-
finitions. Women with hypertension but without proteinuria were not
considered to have preeclampsia and therefore were not treated ac-
cording to the ‘new’ preeclampsia protocols, which would include
hospital admission and in severe cases inducing labor from 34 weeks.
On the basis of the comparison of the complications between the two
groups, this seems justified.
For secondary outcome we aimed to evaluate if women with non-
proteinuric preeclampsia are equally at risk for short-term pregnancy
complications compared to women with proteinuric preeclampsia. We
found no differences in short-term complications, except for a lower
number of NICU admission in the non-proteinuric group. However,
there was a high chance of type II error because of the small sample
sizes. Due to the retrospective study design we did not have follow-up,
which made it impossible to analyse the long-term complications and
course of the different preeclampsia subgroups. We therefore re-
commend further research into the course and long-term prognosis of
especially non-proteinuric preeclampsia.
7. Conclusion
The use of the ‘new’ ISSHP and ACOG definitions for hypertensive
disorder causes an increase in cases of preeclampsia and superimposed

Table 7
Causes of the shift in diagnoses using the ACOG 2013 criteria.
Preeclampsia ACOG 2013 Superimposed preeclampsia ACOG 2013 Total preeclampsia** ACOG 2013

Caused by maternal organ dysfunction without proteinuria * 14 2 16

Renal insufficiency 4 (28,6%) 1 (50,0%) 5 (31,3%)
Liver involvement 7 (50,0%) 2 (100,0%) 9 (56,3%)
Neurological complications – – –
Hematological complications 9 (64,3%) 1 (50,0%) 10 (62,5%)
Lung edema 1 (7,1%) 2 (100%) 3 (18,8%)
total 14 2 16

Causes of the shift in diagnoses using the ACOG 2013 criteria.

*Used ACOG 2013 cut off values as shown in Table 1.
**Preeclampsia + chronic hypertension with superimposed preeclampsia.

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Table 8
Maternal and neonatal complications in proteinuric and non-proteinuric preeclampsia.
Proteinuric PE ISSHP (2018)/ACOG (2013) Non-proteinuric PE ISSHP Non-proteinuric PE ACOG (2013) P-value
N = 218 (2018) N = 15
N = 75

Maternal complications, n. (%) 15 (6,9%) 6 (8%) 1 (6,7%) 0,635a 0,985b

Preterm birth * n. (%) < 32 weeks 80 (36,7%) 12 (16,1%) – 0,074a
Birth weight ** n. (%) 66 (30,3%) 12 (16,1%) 1 (6,67%) 0,062a
0,055b
Admitted to the NICU, n. (%) 96 (44,0%) 19 (25,3%) 2 (13,3%) 0,019a ***
0,011b,***
Perinatal death, n. (%)
< 24 h 2 (0,9%) 2 (0,7%) 2 (0,9%) 0,997a
< 7 days – – – 0,999b

*Preterm birth = gestational age at birth < 32 weeks.

**Low birth weight = birth weight < 1250 g.
***p < 0,05.
a
PE ISSHP(2001) compared to non-proteinuric PE ISSHP (2018).
b
PE ISSHP (2001) compared to non-proteinuric PE ACOG (2013).

preeclampsia. It is likely that this will lead to an increase in hospital References

admission between 24 and 37 weeks of gestation and an increase in the
number of inductions of labor. Half of the preeclampsia cases showed
severe features according to the ACOG 2013 criteria. Evaluation of
short-term pregnancy complications of the non-proteinuric pre-
eclampsia cases showed almost no differences when compared to the
proteinuric preeclampsia cases. Only neonatal NICU admission rates
were almost doubled in the proteinuric preeclampsia group. However,
since the low incidence of these complications this effect has to be re-
evaluated in other studies. Research into the long-term course of non-
proteinuric preeclampsia is also recommended.
All authors contributed to writing the manuscript and approved the
final version. All authors were responsible for the manuscript pre-
paration. All authors revised the article critically for important in-
tellectual content and approved the final version to be published. The
authors report no conflicts of interest.
Acknowledgements
We would also like to acknowledge Mark Wildhagen, for providing
us the cohort to create our data set to conduct our study.
[1] D.M. Carty, C. Delles, A.F. Dominiczak, Preeclampsia and future maternal health, J.
Hypertens. 28 (2010) 1349–1355.
[2] J.M. Roberts, M.J. Bell, If we know so much about preeclampsia, why haven't we
cured the disease? J. Reprod. Immunol. 99 (2013) 1–9.
[3] C.M. Koopmans, D. Bijlenga, H. Groen, S.M. Vijgen, J.G. Aarnoudse, et al., Induction
of labour versus expectant monitoring for gestational hypertension or mild pre-
eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label rando-
mised controlled trial, Lancet 374 (2009) 979–988.
[4] K. Broekhuijsen, G.J. van Baaren, M.G. van Pampus, W. Ganzevoort, et al.,
Immediate delivery versus expectant monitoring for hypertensive disorders of
pregnancy between 34 and 37 weeks of gestation (HYPITAT-II): an open-label,
randomised controlled trial, Lancet 387 (2016) 848.
[5] J. Kallela, T. Jaaskelainen, E. Kortelainen, S. Heinonen, E. Kajantie, J. Kere, et al.,
The diagnosis of pre-eclampsia using two revised classifications in the Finnish Pre-
eclampsia Consortium (FINNPEC) cohort, BMC Pregnancy Childbirth 16 (2016) 221.
[6] E.A. Steegers, P. von Dadelszen, J.J. Duvekot, R. Pijnenborg, Pre-eclampsia. Lancet
376 (2010) 631–644.
[7] A.L. Tranquilli, G. Dekker, L. Magee, J. Roberts, B.M. Sibai, W. Steyn, et al., The
classification, diagnosis and management of the hypertensive disorders of pregnancy:
A revised statement from the ISSHP, Pregnancy Hypertens 4 (2014) 97–104.
[8] Pregnancy. ACoOaGTFoHi, Hypertension in pregnancy. Report of the American
College of Obstetricians and Gynecologists' task force on hypertension in pregnancy,
Obstet. Gynecol. 122 (2013) 1122–1123.
[9] M.A. Brown, L.A. Magee, L.C. Kenny, S.A. Karumanchi, et al., Hypertensive Disorders
of Pregnancy: ISSHP Classification, diagnosis & management recommendations for
international practice, Pregnancy Hypertens. 13 (2018) 291–310.

211