Risk Factors For Pre-Eclampsia in Clinical Practice Guidelines: Comparison With The Evidence

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Accepted: 6 September 2022
DOI: 10.1111/1471-0528.17320
RESEARCH ARTICLE
Risk factors for pre-eclampsia in clinical practice guidelines:

Comparison with the evidence
Terteel Elawad1,2 | Georgia Scott1,3 | Jeffrey N. Bone4,5 | Helen Elwell6 |

Cristina Escalona Lopez1 | Veronique Filippi7 | Marcus Green8 | Asma Khalil9 |
Mai-Lei W. Kinshella4,5 | Hiten D. Mistry1 | Kelly Pickerill4,5 | Reshma Shanmugam1,10 |
Joel Singer11,12 | Rosemarie Townsend9 | Eleni Z. Tsigas13 | Marianne Vidler4,5 |
Marie-Laure Volvert1 | Peter von Dadelszen1,4,5 | Laura A. Magee1,4,5 | the PRECISE Network
1
Department of Women and Children's
Health, School of Life Course Sciences, Abstract
Faculty of Life Sciences and Medicine, King's Objective: To compare pre-eclampsia risk factors identified by clinical practice
College London, London, UK
2
guidelines (CPGs) with risk factors from hierarchical evidence review, to guide pre-
Barts and the London School of Medicine and
Dentistry, Queen Mary University of London, eclampsia prevention.
London, UK Design: Our search strategy provided hierarchical evidence of relationships between
3
North West London Foundation School, risk factors and pre-eclampsia using Medline (Ovid), searched from January 2010 to
London, UK January 2021.
4
Department of Obstetrics and Gynaecology, Setting: Published studies and CPGs.
University of British Columbia, British
Columbia, Vancouver, Canada Population: Pregnant women.
5
BC Children's Hospital Research Institute, Methods: We evaluated the strength of association and quality of evidence (GRADE).
University of British Columbia, British CPGs (n = 15) were taken from a previous systematic review.
Columbia, Vancouver, Canada Main outcome measure: Pre-eclampsia.
6
British Medical Association (BMA) Library, Results: Of 78 pre-eclampsia risk factors, 13 (16.5%) arise only during pregnancy.
BMA, London, UK
7
Strength of association was usually ‘probable’ (n = 40, 51.3%) and the quality of evi-
London School of Hygiene and Tropical
Medicine, London, UK dence was low (n = 35, 44.9%). The ‘major’ and ‘moderate’ risk factors proposed by
8
Action on Pre-Eclampsia (APEC), Evesham, UK 8/15 CPGs were not well aligned with the evidence; of the ten ‘major’ risk factors
9
St George's Hospital NHS Foundation Trust, (alone warranting aspirin prophylaxis), associations with pre-eclampsia were defi-
London, UK nite (n = 4), probable (n = 5) or possible (n = 1), based on moderate (n = 4), low (n = 5)
10
West Midlands Central Foundation School, or very low (n = 1) quality evidence. Obesity (‘moderate’ risk factor) was definitely
Birmingham, UK associated with pre-eclampsia (high-quality evidence). The other ten ‘moderate’
11
School of Population and Public Health, risk factors had probable (n = 8), possible (n = 1) or no (n = 1) association with pre-
University of British Columbia, British
Columbia, Vancouver, Canada eclampsia, based on evidence of moderate (n = 1), low (n = 5) or very low (n = 4) qual-
12
Centre for Health Evaluation and Outcome ity. Three risk factors not identified by the CPGs had probable associations (high
Sciences, University of British Columbia, quality): being overweight; ‘prehypertension’ at booking; and blood pressure of
British Columbia, Vancouver, Canada 130–139/80–89 mmHg in early pregnancy.
13
Preeclampsia Foundation, Florida, Conclusions: Pre-eclampsia risk factors in CPGs are poorly aligned with evidence,
Melbourne, USA
particularly for the strongest risk factor of obesity. There is a lack of distinction be-
Correspondence tween risk factors identifiable in early pregnancy and those arising later. A refresh of
Laura A. Magee, Addison House, Guy's the strategies advocated by CPGs is needed.
Campus, Great Maze Pond, London, UK.
Email: [email protected]
Terteel Elawad and Georgia Scott Shared first authorship.

Peter von Dadelzen and Laura A Magee Shared senior authorship.
Members of the PRECISE network are listed in Appendix S1.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the
original work is properly cited.
© 2022 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.
BJOG: Int J Obstet Gy. 2022;00:1–17. wileyonlinelibrary.com/journal/bjo | 1

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|
2 ELAWAD et al.
Funding information
United Kingdom Research and Innovation K EY WOR DS
GCRF, Grant/Award Number: MR/P027938/1 determinants, outcomes, pre-eclampsia, prevention, risk factors
1 | I N T RODUC T ION 2 | M ET HODS
Pre-eclampsia complicates 2%–4% of pregnancies world- 2.1 | Systematic review of CPGs

wide and its incidence is rising, given the current trends
in advanced maternal age of pregnancies and rising body In a previous systematic review, 17 CPGs were identified for
mass.1 Pre-eclampsia is the hypertensive disorder of preg- guidance on the diagnosis, evaluation and management of
nancy (HDP) associated with the greatest risk of mater- HDPs.6 Full details of our methodology have already been
nal and fetal morbidity and mortality. As such, a large published.6
part of prenatal care is devoted to the detection of pre- In brief, we searched online databases (MEDLINE,
eclampsia, through blood pressure (BP) and proteinuria EMBASE, Cochrane Central Register of Controlled Trials,
screening. 2 However, as there is currently no approved Health Technology Assessments, the Database of Abstracts
disease-modifying treatment for pre-eclampsia, current of Reviews of Effects and grey literature) using appropri-
best practice remains the identification of women at ate keywords and Medical Subject Headings (MeSH), from
risk, the use of preventative therapy, 3 the management January 2009 to October 2019, to identify CPGs meeting our
of hypertension and other organ manifestations should eligibility criteria.6 A CPG was defined as an evidence-based
pre-eclampsia develop and, ultimately, timed birth, as document that offered structured advice for healthcare pro-
the only intervention that initiates the resolution of this fessionals, referenced primary literature and was issued by
syndrome. a professional medical society, government body or similar
There is international consensus that screening for pre- organisation. Included were CPGs in English, French, Dutch
eclampsia risk should occur in early pregnancy, to evaluate or German that covered the diagnosis, assessment and
whether there is an indication for evidence-based preven- management of at least one HDP, or were explicit updates
tative measures (e.g. aspirin).4 Whilst adding biochemical to the CPGs described by Gillon et al.8 Excluded were publi-
markers and ultrasonographic factors to clinical risk factors cations that were adapted only from existing CPGs or were
can double the identification of women who will develop local or regional in scope when there was a relevant national
pre-eclampsia before 37 weeks of gestation (i.e. preterm pre- document.
eclampsia),5 clinical risk factors remain important for pre- The quality of CPGs was assessed by three indepen-
eclampsia prediction, including risk factors that develop dent reviewers (GS, LAM and PvD) using the Appraisal
later in pregnancy and mandate enhanced surveillance and of Guidelines for Research & Evaluation Instrument II
timed birth. (AGREE II) tool,9 and disagreements were resolved through
Clinical practice guidelines (CPGs) are intended to ad- consensus. AGREE-II has six domains, including rigour of
vise clinicians on high-quality, evidence-based practice. We development, the domain that best represents the standard
previously conducted a systematic review of international of literature search and the overall quality of evidence used
CPGs for the HDPs, assessing and comparing the quality in guideline development. For the 15 CPGs deemed to be
of CPGs and their recommendations.6 Although almost all clinically useful after AGREE-II assessment, structured ta-
current CPGs for pregnancy hypertension list risk factors bles were used to abstract pre-eclampsia risk factors from
for pre-eclampsia, the quality of the documents vary, as do recommendations, tables, bullet points or text.8 Summary
the screening recommendations.6 This variability can be information about risk factors designated by CPGs as ‘major’
difficult to understand, given the limited referencing per- or ‘moderate’ have previously been reported; here, this in-
missible when guidelines are published in peer-reviewed formation is presented by risk factor and CPG, along with
journals. details of the other risk factors listed and types of sources
As part of the development of a framework of pre- cited, according to in-text citation.
eclampsia risk factors,7 we undertook an evidence review of
the determinants of pre-eclampsia (Elawad T. A conceptual
framework for the determinants of pre-eclampsia. A disser- 2.2 | Evidence review for pre-eclampsia
tation submitted in partial fulfilment of the requirements risk factors
for the degree at the King's College London, Department of
Women and Children's Health, Faculty of Life Sciences and We used the methods of Hiatt et al. to develop a compre-
Medicine). In this analysis, we sought to compare the risk hensive model for the determinants of pre-eclampsia.10 A
factors for pre-eclampsia identified in CPGs, and the under- broad group of experts in pre-eclampsia was assembled from
lying evidence base. the Epidemiology Working Group of the PREgnancy Care
PRE-ECLAMPSIA RISK: CLINICAL GUIDELINES VS EVIDENCE |
3
Integrating translational Science, Everywhere (PRECISE) (or calculated from the Q statistic) to reflect heterogeneity.
Network.7 A working model of determinants of pre- RR and OR were used interchangeably for the model, as
eclampsia was expanded from variables found to have sig- pre-eclampsia occurs in <10% of the unexposed population,
nificant associations with pre-eclampsia by pooled results making the OR a reasonable approximation of the RR.17
in umbrella reviews (i.e. systematic reviews of systematic Recommendations prepared by Grading of
reviews).11,12 Recommendations, Assessment, Development, and
Evaluation (GRADE) were used to assess the quality of
the evidence, as high, moderate, low or very low. A cross-
2.2.1 | Literature search disciplinary team (M-LV, KP, TE, CEL, MW-K, MV, JF, RS,
HDM) adapted GRADE criteria through consensus into a
The search strategy was developed in consultation with a standardised process for this pregnancy project, to minimise
clinical librarian (HE) at the British Medical Association. discrepancies between reviewers.18,19 Table 1 shows that as
In brief, Medline (Ovid) was searched from January 2010 a starting point, umbrella or systematic reviews were con-
to January 2021, using keywords covering all potential de- sidered to be of high quality and observational studies were
terminants of pre-eclampsia. The highest level of evidence considered to be of low quality.20 However, the final qual-
supporting a relationship between a risk factor and pre- ity rating for each methodology could be modified based on
eclampsia was identified in a hierarchical fashion. Umbrella additional characteristics: decreased, based on study limita-
reviews were sought that focused on pre-eclampsia, and tions (risk of bias), important inconsistency, indirectness,
only if none were identified were the keywords broadened imprecise data or publication bias; or increased, based on
to identify any studies in pregnancy. If no relevant umbrella large effect size or dose–response gradient. One reviewer
reviews were identified, then the process was repeated to (TE) assessed the quality of the evidence using these GRADE
identify relevant systematic reviews. If no systematic reviews criteria, and any uncertainty was resolved by discussion and
were identified or identified for all risk factors of interest, consensus reached with a second and third reviewer (CEL
then large observational studies (including secondary anal- and RS).
yses of trials) were sought, searching individually for rel-
evant risk factors. Observational studies with at least 1000
participants were targeted, as described by Bartsch et al.,13 2.3 | Comparison of CPG risk factors
to be more representative of the general population and to with the literature
have sufficient statistical power to assess less prevalent, but
potentially important, risk factors.14 Smaller observational A descriptive comparison of pre-eclampsia risk factors was
studies, case reports or series, qualitative reviews and edi- made between those identified in CPGs and those identified
torials were excluded. (For details, including keywords, see from the literature search. The strength of association with
Table S3.) pre-eclampsia and the quality of the underlying evidence
were assigned and compared with the CPG, with an overall
designation of risk factors as ‘major’ or ‘moderate’. Risk fac-
2.2.2 | Data extraction tors are presented according to traditional history taking, as
demographics and social determinants of health, past his-
Titles and abstracts of articles were screened to assess eligi- tory, family history and current pregnancy.
bility. Potentially eligible studies underwent full-text review.
Data abstracted were general study characteristics, strength
of association between each risk factor and pre-eclampsia 3 | R E SU LT S
(estimated as relative risk (RR), odds ratio (OR) or diagnos-
tic OR (DOR), and reported, adjusted where possible, or cal- 3.1 | CPGs
culated from the prevalence of pre-eclampsia among women
with and without the risk factor), and the characteristics The 15 CPGs previously identified by AGREE-II as ‘clini-
necessary to assess study quality. Subcategories of a potential cally useful’ were included in this analysis,21–44 as described
risk factor were also considered, such as a body mass index in the prior systematic review (Table S2).6 In brief, most
(BMI) categorised as overweight or obese. CPGs (n = 13) were national in scope and produced by pro-
As described by Hiatt et al.,10 the strength of associa- fessional societies. On the AGREE-II ‘rigor of development’
tion between risk factors and the outcome of interest (pre- domain, few CPGs scored ≥80%,21–24,43,41 and some scored
eclampsia) was evaluated as definite, probable, possible or <40%.33,35–39,42,44
not significant.15 The evaluation was based on point esti- All but the Brazilian guideline (i.e. 14/15 CPGs) listed risk
mates, extracted as reported or calculated from primary data factors for pre-eclampsia.6 Just over half of the CPGs (8/14)
using previously published cut-offs (Table 1).10,16 If a study stratified risk factors into levels of importance. When listed
reported outcomes as proportions, a RR was calculated as a as ‘major’/’high’ and ‘moderate’ risk factors (n = 6; NED,
simple ratio between those with the risk factor of interest and IRL, European Society of Cardiology (ESC),26 American
those without. Results of the I2 statistic were also extracted College of Obstetricians and Gynecologists (USA),30–32
| 4
T A B L E 1 Strength of association between risk factors and pre-eclampsia based on point estimates of various summary measures
Quality of evidence
Initially High Moderate Low Very low

Umbrella review or systematic review – Observational study (N > 1000) –
Evaluation/ Risk of bias Inconsis- tencyc Indirect-nessc Impreci-sionc Publication biasc Magni-t ude of Dose-g radient
scoring effectc response
1↓ Lack of inclusion 1↓ I2 > 50% Excludes 1↓ Sample size 1↓ Asymmetrical 1↑ Large: RR > 2– 1↑ if existent
or discussion women <1000 funnel 5 or 0.5–0.2
of sensi-t ivity from or not plots or no OR 2↑ very
analysis AND/ population reported mention of large: RR > 5
OR 1↓ Study 1↓ serious AND/ public-c ation or RR <0.2
limitations 2↓ very serious OR 1↓ CI bias AND 1↓
crosses 1.0 evidence of
very strong
publication
bias
RR or OR a DOR b LR Final High Moderate Low Very low
Strength of (↑risk) (↓ risk) LR+ LR−

association
Definite ≥3.00 <0.33 ≥100 >10 <0.1
Probable 1.50–2 .99 0.33–0.67 >25 to <100 5.01–10.0 0.10–0.19
Possible 1.10–1.49 >0.67–<0.9 >4 to ≤25 2.01–5.0 0.20–0.50
Not significant 0.90–1.09 1–4 1.0–2 .0 0.51–0.99
Note: The initial grade category was altered, by one or two categories (up to the left, or down to the right), depending on characteristics other than the study design, according to GRADE.
Abbreviations: DOR, diagnostic odds ratio; LR, likelihood ratio; LR−, negative LR; LR+, positive LR; NS, not significant; R, odds ratio; RR, relative risk.
a
Based on Hiatt et al.10
b
Based on LR+ and LR− criteria and definition of DOR as LR+/LR−.
c
Inconsistency was defined as variation between studies (heterogeneity), indirectness whether the paper answered the question we aimed to answer; imprecision defined according to the confidence interval of the summary estimates,
publication bias, as a tendency towards publication of studies that showed positive results, and magnitude of effect, as determined by the RR.
ELAWAD et al.
PRE-ECLAMPSIA RISK: CLINICAL GUIDELINES VS EVIDENCE |
5
National Institute for Health and Care Excellence (UK), CPGs (in bold), associations ranged from definite to possible
Polish Society of Hypertension (POL)), aspirin was recom- and the quality of evidence ranged from moderate to very
mended for one ‘major’ risk factor or at least two ‘moder- low. For risk factors designated as ‘moderate’ by the CPGs,
ate’ factors. Other CPGs presented lists of risk factors to (in italics), associations ranged from definite to none and
identify ‘increased risk’; sometimes highlighting factors quality of evidence ranged from high to very low.
associated with a particularly high risk, designated here as Our hierarchical search strategy identified 41 studies to
‘major’ (n = 2; Society of Obstetricians and Gynaecologists support or refute determinants of pre-eclampsia: two um-
of Canada (CAN),28,29 Ministry of Health, New Zealand brella reviews that supported 25 risk factors, 11,12 14 system-
(NZL)), or otherwise presenting a list with no associated atic reviews or meta-analyses covering an additional 15 risk
strength of association (n = 6; World Health Organization factors,48–61 and 25 large observational studies supporting
(WHO), Society of Obstetric Medicine of Australia and 28 additional risk factors.62–86 Our strategy identified no ev-
New Zealand (SOMANZ),43 French Society of Hypertension idence meeting our criteria for ten risk factors.
(FRA),34 La Société Tunisienne de Gynécologie Obstétrique Table 3 shows that the 78 risk factors evaluated were de-
(TUN), International Society for the Study of Hypertension rived from demographics and social determinants of health
in Pregnancy (ISSHP),27 and German Society of Gynecology (n = 8), past medical (n = 27), obstetric (n = 10) and family
and Obstetrics (DEU)40). (n = 5) histories, and conditions arising early or later during
The CPGs varied with regards to the provision of in-text the current pregnancy (n = 28). The strength of association
citations for risk factors. Three CPGs cited no such sup- and quality of evidence are presented along with the CPGs
porting literature (WHO, IRL and ESC), which when pro- that endorsed them.
vided, was not necessarily linked with the risk factors cited.
Supporting publications were guidelines (CAN, SOMANZ,
NZL, DEU, POL, NED, UK), systematic reviews (CAN, 3.2.1 | Definite associations
SOMANZ, NZL, DEU, ISSHP, NED, USA), observational
studies (CAN, SOMANZ, NZL, DEU, USA, FRA, TUN, There were eight risk factors with definite associations with
UK), narrative reviews (CAN, SOMANZ, NZL, DEU, FRA, pre-eclampsia (shown in dark green, Table 3): demographics
UK), commentaries (CAN, SOMANZ, NZL, DEU, FRA), (adolescence); past medical history (obesity, chronic hyper-
books (CAN, SOMANZ, NZL, DEU) and a health tech- tension, pre-gestational diabetes mellitus (DM), considered
nology assessment report (UK). Some guidelines quoted as type-1 and type-2 DM separately, and severe anaemia);
systematic reviews published more than 10 years prior (e.g. past obstetric history (prior pre- eclampsia); and current
Duckitt et al. 2005,45 cited by CAN, SOMANZ, NZL, DEU; pregnancy (fetal trisomy 13).
and Conde-Agudelo et al. 2000,46 cited by USA) rather than Obesity (i.e. BMI ≥ 30 kg/m2) was the only risk factor with
more recent reviews (e.g. Bartsch et al. 2016,13 cited by NED, a ‘definite’ association with pre-eclampsia based on high-
ISSHP, USA). quality evidence (n = 14 CPGs). No CPG, even those that
highlighted only a subgroup with BMI ≥ 35 mg/kg2 (NED,
IRL, TUN, NZL, ESC, UK, POL), endorsed obesity as a
3.2 | Evidence ‘major’ risk factor, whereas 6/14 regarded it as a ‘moderate’
risk factor.
Eighty pre-eclampsia risk factors were identified. Two, pro- Moderate-quality evidence supported four risk factors
posed by one CPG each, were not considered further because that were generally highly endorsed by CPGs: prior pre-
they were considered both vague and covered by individual eclampsia (n = 10 CPGs, 4/10 ‘major’), chronic hypertension
conditions already included as risk factors: any ‘prior ad- (n = 13, 8/13 ‘major’), type-2 DM (n = 14 as ‘pre-gestational
verse pregnancy outcome’ and any ‘placental insufficiency DM’, 8/14 ‘major’) and trisomy 13 (n = 1).
in obstetric history’. Low-quality evidence supported three risk factors: ad-
Table 2 presents the 78 risk factors for pre-eclampsia, olescence (endorsed only by WHO), type-1 DM (n = 14 as
according to their strength of association and quality of ‘pre-gestational DM’, 8/14 ‘major’) and severe anaemia (not
evidence, and whether they are generally evident in early endorsed).
pregnancy (n = 60 white table cells and n = 4 footnoted for a
lack of evidence), or become evident only as pregnancy pro-
gresses (n = 8, blue table cells, and n = 6 footnoted for a lack 3.2.2 | Probable associations
of evidence), recognising that there are some additional fac-
tors that could be both, such as anxiety or anaemia. First, ten The majority of associations (n = 39) with pre-eclampsia
‘major’ and 11 ‘moderate’ risk factors were designated by the were probable (shown in medium green, Table 3).
CPGs, two of which were both ‘major’ and ‘moderate’ risk High-quality evidence supported three risk factors.
factors (i.e. multiple pregnancy and ART), and all of which Overweight (i.e. BMI = 25.0–29.9 kg/m2) and stage-1 hy-
can be identified in early pregnancy. Second, the strength pertension (defined as systolic BP 130– 139 mmHg and/
of association and quality of evidence for risk factors were or diastolic BP 80–89 mmHg at booking or <20 weeks of
not closely aligned. For risk factors designated as ‘major’ by gestation)47 were endorsed by few CPGs (i.e., n = 2 and 3,
|
6 ELAWAD et al.
T A B L E 2 Matrix of risk factors for pre-eclampsia, according to strength of association and quality of evidencea
Quality of evidence
High (N = 4) Moderate (N = 11) Low (N = 35) Very low (N = 18)
Strength of Definite CPGs Obesity Prior pre-eclampsia Adolescence –

association (N = 8) (BMI ≥ 30kg/m2) Chronic hypertension Type-1 DM
Type-2 DM
Fetal trisomy 13
New – – Severe anaemia –
Probable CPGs Overweight Antiphospholipid Maternal age > 40 years Artificial reproductive
(N = 39) Early pregnancy antibody syndrome Systemic lupus erythematosusc technology
Stage- Smoking (↓risk) Chronic kidney disease African American (black)
1hypertensionb Obstructive sleep Thrombophilia
apnoea Nulliparity
Family history in mother Multiple pregnancy
or sister New or change in partner
Family history (relation
unspecified)
Prior miscarriage at ≤10 weeks
with same partner (↓risk)
Methamphetmine use
Sub-Saharan African
South Asian
Maori
Any infection in current Excessive weight gain Fetal trisomy 21
pregnancy GDM
New Booking Prior stillbirth Sickle cell disease Recurrent miscarriage
prehypertensionc Rheumatoid arthritisc Barrier contraception
Polycystic ovarian syndrome
Periodontal disease
Helicobacter pylori
Depression
Placental abruption prior
pregnancy
Prior preterm birth
Anaemia
Family history of CVD
Possible CPGs – – Prior HDP Interpregnancy interval
(N = 13) Prior lower maternal birthweight ≥10 years
or preterm birth Duration of sexual relationship
Abnormal uterine artery Doppler <12 months
in current pregnancy Family history in the father
Pacific Islander Low socio-economic status
New – Urinary tract infection Hepatitis B infection Stress
(current pregnancy) Previous miscarriage (timing and Endometriosis
number unspecified)
Not significant CPGs – – – Prior SGA infant
(N = 8) Vaginal bleeding in early
(current) pregnancy
Fetal trisomy 18
New – – – Thalassemia
HIV
Tuberculosis
Anxiety
Malaria (current pregnancy)
Abbreviations: BMI, body mass index; CVD, cardiovascular disease; DM, diabetes mellitus; HDP, hypertensive disorder of pregnancy; HIV, human immunodeficiency virus;
SGA, small for gestational age.
a
Risk factors listed in bold type are those listed by one or more CPG as a ‘major’ risk factor; risk factors listed in italics are listed as a ‘moderate’ risk factor. Factors in white
cells are known in early pregnancy, whereas those in blue cells are risks that become evident as pregnancy progresses. The following factors endorsed by CPGs are excluded,
as there was no rigorous evidence identified to evaluate their association with pre-eclampsia: ‘autoimmune disease’ as a group, elevated prepregnancy triglycerides, family
history of early-onset CVD, gestational hypertension, FGR, fetal triploidy, hyperplacentation (not otherwise specified), fetal hydrops, gestational trophoblastic disease, and
cocaine use.
b
According to American College of Cardiology/American Heart Association criteria, prehypertension is systolic BP < 120–129 mmHg with diastolic BP < 80 mmHg, and
stage-1 hypertension is systolic BP 130–139 mmHg and/or diastolic BP 80–89 mmHg.47
c
Abnormal uterine artery Doppler included bilateral notching, or an increased pulsatility or resistance index persisting beyond 24 weeks gestational age.
PRE-ECLAMPSIA RISK: CLINICAL GUIDELINES VS EVIDENCE
7|
respectively), and none were designated as ‘major’ or ‘mod- A summary of risk factors with a demonstrated associa-
erate’ risk factors. No CPGs endorsed prehypertension at tion with pre-eclampsia are presented in Table 4.
booking as a risk factor.
Moderate- quality evidence supported six risk factors.
Antiphospholipid antibody syndrome (APAS, n = 12 CPGs, 4 | DISC US SION
8/12 ‘major’) was highly endorsed and family history of
pre-eclampsia in mother or sister (n = 5, 1/5 ‘major’ and 3/5 4.1 | Summary of findings
‘moderate’) was also endorsed by the CPGs. Other risk fac-
tors were endorsed by one CPG each (i.e. obstructive sleep The CPG-recommended pre-eclampsia risk factors are not
apnoea, smoking and any infection in the index pregnancy). well aligned with the published evidence. ‘Major’ risk fac-
No CPG endorsed prior stillbirth. tors usually have definite to probable associations with pre-
Low-quality evidence supported 25 risk factors, including eclampsia, based on moderate-to very low-quality evidence,
five that were highly endorsed by the CPGs: maternal age of with two exceptions. ‘Prior HDP’ has a possible association,
>40 years (n = 10 CPGs, 5/10 as ‘moderate’ with an 11th CPG based on low-quality evidence. ‘Autoimmune disease’ has
identifying maternal age >35 years as ‘moderate’), systemic no supporting evidence but includes conditions for which
lupus erythematosus (SLE, n = 8, 7/8 ‘major’), chronic kid- there is low-quality evidence (e.g. rheumatoid arthritis).
ney disease (CKD, n = 14, 8/14 ‘major’), multiple pregnancy ‘Moderate’ risk factors in general have weaker relationships
(n = 14, 2/14 ‘major’ and 5/14 ‘moderate’) and nulliparity with pre-eclampsia, based on lower quality evidence, but
(n = 12, 6/12 as ‘moderate’). maternal obesity is a notable exception.
Very low-quality evidence supported five risk factors, Indeed, obesity is the strongest evidence-informed pre-
including the well-endorsed ART (n = 7 CPGs, 1/7 ‘major’ eclampsia risk factor, having a definite association with pre-
and 1/7 ‘moderate’); oocyte donation, specified in 3/7 of the eclampsia, based on high-quality evidence. Also, there are
CPGs that specified ART, was listed as both a ‘major’ and other evidence-informed risk factors that are listed as nei-
‘moderate’ risk factor in different guidelines. ther ‘major’ nor ‘moderate’ in the guidelines, particularly
maternal overweight and stage-1 hypertension or prehyper-
tension at booking, based on high-quality evidence.
3.2.3 | Possible associations A number of pre-eclampsia risk factors are of particular
relevance to low-and middle-income countries (LMICs).
There were 13 possible associations with pre- eclampsia Some factors have definite (i.e. adolescence or severe anae-
(shown in very light green, Table 3). Only evidence of mod- mia) or probable (i.e. sickle cell disease or anaemia) associa-
erate quality supported urinary tract infection in the index tions with pre-eclampsia, yet only adolescence is listed, and
pregnancy (n = 1 CPG). Low-quality evidence supported six then only by the WHO. Although no association with pre-
risk factors, including ‘prior HDP’, endorsed by n = 4 CPGs, eclamspia is demonstrable for other risk factors (i.e. HIV,
with all listing this as a ‘major’ risk factor. Very low-quality tuberculosis and malaria), the quality of evidence is very low.
evidence supported six risk factors, including an interpreg- The CPGs focus on pre-eclampsia risk factors identi-
nancy interval of ≥10 years, which was endorsed by many fied in early pregnancy to guide low-dose aspirin therapy.
CPGs (n = 9) and frequently listed as a ‘moderate’ risk factor However, there are additional, well-supported risk factors
(in 6/9). that become evident as pregnancy progresses and influence
investigations, maternal– fetal surveillance and/or timed
birth. Examples include common conditions in pregnancy,
3.2.4 | Not significant like anaemia (particularly severe anaemia), infections, ges-
tational weight gain and gestational DM.
According to our methodology, no association could be dem-
onstrated for eight risk factors, all based on very low-quality
evidence (Table 3). Three were endorsed by a single CPG: 4.2 | Comparison with current literature
prior small-for-gestational-age (SGA) infant (as ‘moderate’),
fetal trisomy 18 and vaginal bleeding in early pregnancy. To our knowledge, this is the first evidence-informed com-
According to our methodology, no rigorous evidence parison of pre-eclampsia risk factors with those endorsed by
was found to evaluate ten risk factors. With the exception of CPGs. Deserving of specific mention is the only ‘possible’
‘autoimmune disease’ (as a group), endorsed by many CPGs association between pre-eclampsia and ‘prior HDP’; this
(n = 9, 5/9 as ‘major’), these risk factors were endorsed by one risk factor was cited as a ‘major’ risk factor by four CPGs,
or two CPGs: increased pre-pregnancy triglycerides (n = 1); whereas the others cited ‘prior pre-eclampsia’ as a major risk
family history of early-onset cardiovascular disease (CVD) factor, and for that, there is a definite relationship.
(n = 1); gestational hypertension (n = 2); fetal growth re- Although we demonstrated a lack of close alignment
striction (FGR) (n = 1); hyperplacentation, unspecified; fetal between the guideline risk factors and the evidence, it was
hydrops (n = 2); gestational trophoblastic disease (n = 2); fe- not usually possible to understand why this was the case.
toplacental triploidy (n = 1); and cocaine use (n = 1). Guidelines usually cite one reference in support of all the
|
8 ELAWAD et al.
T A B L E 3 Risk factors for pre-eclampsia
Conceptual framework Clinical practice guidelines6

Risk factor (and conceptual
framework reference(s) when Strength of Quality of
unavailable) associationa evidenceb N endorsing risk factor ‘High, major or strong’ ‘Moderate’
Demographics
Maternal age
Adolescence54 Definite Low N = 1 (WHO) None None
Advanced maternal age Probable Low N = 10 (NLD, CAN, SOMANZ, None N = 5 (NLD, IRL,
(>40 years in CPGs)11 IRL, TUN, NZL, ESC, DEU, ESC, UK,
UK, POL) POL)
Ethnicity
black66 Probable Very low N = 2 (USA, DEU) None N = 1 (USA)
78
(Sub-Saharan) African Probable Low N = 1 (NZL) None None
South Asian72 Probable Low N = 1 (NZL) None None
73
Pacific Islander Possible Low N = 1 (NZL) None None
Maori75 Probable Low N = 1 (NZL) None None
C67
Low socio-economic status Possible Very low N = 1 (USA) None N = 1 (USA)
Past medical history
BMI (kg/m2)
Obesity (BMI ≥ 30)11,12 Definite High N = 7 (WHO, CAN, SOMANZ, None N = 1 (USA)
FRA, ISSHP, USA, DEU)
BMI ≥ 3511,12 N = 7 (NLD, IRL, TUN, NZL, None N = 5 (NLD, IRL,
ESC, UK, POL) ESC, UK,
POL)
Overweight (BMI = 25.0–29.9)11 Probable High N = 2 (CAN, SOMANZ) None None
Chronic hypertension11 Definite Moderate N = 13 (WHO, NLD, CAN, IRL, N = 8 (NLD, CAN, IRL, None
FRA, TUN, ISSHP, NZL, ESC, NZL, ESC, USA,
USA, DEU, UK, POL) UK, POL)
Pregestational DM
Type 211 Definite Moderate N = 14 (WHO, NLD, CAN, N = 8 (NLD, CAN, IRL, None
Type 158 Definite Low SOMANZ, IRL, FRA, TUN, NZL, ESC, USA,
ISSHP, NZL, ESC, USA, DEU, UK, POL)
UK, POL)
Anaemia
Severe anaemia74 Definite Low None – –
61
Anaemia Probable Low None – –
Sickle cell disease48 Probable Low None – –
74
Thalassemia NS Very low None – –
Obstructive sleep apnoea11 Probable Moderate N = 1 (USA) None None
Autoimmune/rheumatic disease
Antiphospholipid syndrome11 Probable Moderate N = 12 (NLD, CAN, SOMANZ, N = 8 (NLD, CAN, IRL, None
IRL, TUN, ISSHP, NZL, ESC, NZL, ESC, USA,
USA, DEU, UK, POL) UK, POL)
Systemic lupus erythematosus11 Probable Low N = 8 (NLD, IRL, TUN, ESC, NZL, N = 7 (NLD, IRL, ESC, None
USA, UK, POL) NZL, USA, UK,
POL)
Rheumatoid arthritis 64 Probable Low None – –
Unspecified – – N = 9 (WHO, NLD, IRL, N = 5 (NLD, IRL, ESC, None
SOMANZ, TUN, ESC, USA, USA, UK)
DEU, UK)
9|
T A B L E 3 (Continued)

11,12
Chronic kidney disease Probable Low N = 14 (NLD, IRL, FRA, ESC, N = 8 (NLD, IRL, ESC, None
UK, POL, TUN, WHO, CAN, UK, POL, CAN,
SOMANZ, ISSHP, NZL, USA, NZL, USA)
DEU)
Polycystic ovarian syndrome11,12 Probable Low None – –
60
Thrombophilia Probable Low N = 2 (CAN, USA) None None
Infection
Periodontal disease11,12 Probable Low None – –
Helicobacter pylori infection51 Probable Low None – –
Hepatitis B infection11,12 Possible Low None – –
57
HIV NS Very low None – –
Tuberculosis71 NS Very low None – –
Mental health
Depression12 Probable Low None – –
11,12
Stress Possible Very low None – –
Anxiety49 NS Very low None – –
Lower maternal birthweight or Possible Low N = 1 (CAN) None None
preterm delivery 62
Increased prepregnancy – – N = 1(CAN) None None
triglycerides
Past obstetric history
Prior pre-eclampsia11 Definite Moderate N = 10 (WHO, NLD, CAN, N = 4 (NLD, CAN, NZL, None
SOMANZ, FRA, TUN, ISSHP, USA)
NZL, USA, DEU)
Prior stillbirth11 Probable Moderate None – –
Prior abruption11 Probable Low None – –
Prior pre-term birth84 Probable Low None – –
53
Prior HDP Possible Low N = 4 (IRL, ESC, UK, POL) N = 4 (IRL, ESC, UK, None
POL)
Endometriosis55 Possible Very low None – –
Prior SGA (or low birthweight)11 NS Very low N = 1 (USA) None N = 1 (USA)
Prior miscarriage
At ≤10 weeks with same partner68 Probable (↓ Low N = 1 (CAN) None None
risk)
Recurrent77 Probable Very low None – –
Timing and number Possible Low None – –
unspecified76
Family history
Pre-eclampsia
Relation unspecified52 Probable Low N = 5 (SOMANZ, IRL, ESC, DEU, None N = 3 (IRL, ESC,
UK) UK)
In mother or sister69 Probable Moderate N = 5 (NLD, CAN, NZL, USA, N = 1 (NZL) N = 3 (NLD,
POL) USA, POL)
In father of baby70 Possible Very low N = 1 (NZL) None None
69
Cardiovascular disease (any) Probable Low None – –
Early onset – – N = 1 (CAN) None None
(Continues)
|
10 ELAWAD et al.

Current pregnancy
Trisomies
Trisomy 1381 Definite Moderate N = 1 (DEU) None None
80
Trisomy 21 Probable (↓ Very low
risk)
Trisomy 1882 NS Very low
Fetoplacental triploidy – – N = 1 (SOMANZ) None None
11
Smoking Probable (↓ Moderate N = 1 (CAN) None None
risk)
Nulliparity11,12 Probable Low N = 12 (WHO, NLD, CAN, None N = 6 (NLD,
SOMANZ, IRL, TUN, NZL, IRL, ESC,
ESC, USA, DEU, UK, POL) USA, UK,
POL)
Early pregnancy BP
Booking sBP 120–129 mmHg Probable High None – –
(with dBP < 80 mmHg)85
Early pregnancy sBP ≥ 130 or Probable High N = 3 (CAN, NZL, SOMANZ) None None
dBP ≥ 80 mmHg85
Gestational hypertension – – N = 2 (CAN, FRA) None None
FGR – – N = 1 (CAN) None None
Abnormal uterine artery Possible Low N = 3 (CAN, FRA, DEU) None None
Dopplerd11
Infection (any)11,12 Probable Moderate N = 1 (CAN) None None
Urinary tract infection50 Possible Moderate None – –
11
Malaria NS Very low None – –
Multiple pregnancy11 Probable Low N = 14 (WHO, NLD, CAN, N = 2 (CAN, USA) N = 5 (NLD, IRL,
SOMANZ, IRL, FRA, TUN, ESC, UK,
ISSHP, NZL, ESC, USA, DEU, POL)
UK, POL)
Excessive weight gain in Probable Low N = 1 (CAN) None None
pregnancy59
GDM63 Probable Low N = 2 (USA, DEU) None None
56 e
Barrier contraception Probable Very low None – –
New or change in partner65 Probable Low N = 2 (CAN, NZL) None None
Duration sexual relationship Possible Very low N = 1 (CAN) None None
<12 months with current
partner56
ART (includes IVF, sperm donation, Probable Very low N = 7 (NLD, NZL, DEU, CAN, N = 1 (NZL) N = 1 (NLD)
oocyte donation)11 FRA, ISSHP, USA)
Interpregnancy interval ≥10 years83 Possible Very low N = 9 (NLD, CAN, SOMANZ, None N = 6 (NLD,
IRL, NZL, ESC, USA, UK, IRL, ESC,
POL) USA, UK,
POL)
Vaginal bleeding in early NS Very low N = 1 (CAN) None None
pregnancy86
Other hyperplacentation
Unspecified – – N = 1 (WHO) None None
Fetal hydrops – – N = 2 (SOMANZ, DEU) None None
11|

Gestational trophoblastic – – N = 2 (CAN, SOMANZ) None None
disease
Illicit drug use
Cocaine – – N = 1 (CAN) None None
Methamphetamine use79 Probablef Low f N = 1 (CAN) None None
Note: All factors increase the risk of pre-eclampsia unless otherwise indicated (by a ↓ arrow).
Abbreviations: ART, assisted reproductive technologies; BMI, body mass index; BP, blood pressure; dBP, diastolic blood pressure; DM, diabetes mellitus; FGR, fetal growth
restriction; GDM, gestational diabetes mellitus; HDP, hypertensive disorder of pregnancy; HIV, human immunodeficiency virus; IVF, in vitro fertilisation; NS, not
significant; sBP, systolic blood pressure; SGA, small for gestational age.
a
Strength of association was assessed according to relative risk and odds ratio criteria in Table 1.
b
Quality of evidence was assessed according to GRADE criteria, detailed in Table S3.
c
Socio-economic status was based on income.
d
e
The association between barrier contraception and pre-eclampsia was observed among nulliparous women.
f
This assessment was based on a large observational study (retrospective cohort study) excluded from a systematic review that was restricted to case–control studies and had a
far smaller number of women (approximately 500) with methamphetamine exposure.87
risk factors listed, with the relative importance recognised among even women identified as being at high risk,90 and
by ‘major’ or ‘moderate’ designations, without further cita- pregnant women are averse to taking medication in pregnancy,
tions. Very few CPGs included a broad array of higher-order particularly when small risks have been identified.91 Also, the
evidence, such as systematic reviews and large observational universal administration of aspirin would not address the
studies, as in our analysis; the most highly cited system- prevention of term pre-eclampsia or risk factors that require
atic review was over 15 years old.45 No CPG cited umbrella alternative approaches (e.g. exercise for a sedentary lifestyle).
reviews that could have been incorporated into the 2019 Given that screening for pre-eclampsia risk should be
guidelines.11,12 It is common for CPGs to cite other guide- implemented for all pregnant women, a recent systematic
lines, often with little or no citation of primary evidence for review emphasised the importance of the ‘population attrib-
risk factors, even when the CPGs had high scores on rigour utable risk’, related not only to strength of association and
of development. All of this contributes to the sense that al- quality of evidence for the risk factor and pre-eclampsia, but
though there has been much focus on quality rating scales also to how commonly the risk factor occurs, and whether
for guidelines, further improvement is necessary before its relationship with pre-eclampsia is modifiable.13 For ex-
CPGs will effectively translate evidence into practice in the ample, addressing a risk factor with a strong association with
field of pregnancy hypertension. pre-eclampsia but low population prevalence (e.g. APAS)
Pre-eclampsia risk assessment, through counting ‘major’ will have little impact on pre-eclampsia incidence at the pop-
or ‘moderate’ risk factors, detects fewer cases of preterm ulation level; this is more likely to be affected by addressing a
pre-eclampsia than a multivariable approach.5,88 Also, the more common risk factor (e.g. overweight), even if the asso-
most important risk factors identified by the CPGs are not ciation with pre-eclampsia is not as strong.
aligned with the published prediction models,89 which most
commonly identify the following risk factors as important:
BMI (19/40 models), uterine artery pulsatility index (17/40), 4.3 | Strengths and limitations
angiogenic markers (16/40 for both placental growth fac-
tor (PlGF) and pregnancy- associated plasma protein A The strengths of this paper include the comprehensive
(PAPP-A)), ethnicity (14/40) and BP (12/40). The absence search strategies to identify CPGs and evidence for indi-
of angiogenic imbalance as a risk factor for pre-eclampsia vidual risk factors,6 and the use of published methodology
in the CPGs is notable. Also, ‘major’ CPG risk factors were to evaluate the strength of association and the quality of the
not as well supported in these models: prior pre-eclampsia evidence.10 We offer a unique perspective on gaps between
(9/40 models), chronic hypertension (2/40), pre-gestational practice recommendations and evidence-informed risk fac-
diabetes (0 but 2/40 included fasting blood glucose), CKD tors, even within guidelines rated as being of high quality.
(0 although 1/40 included serum creatinine), SLE (0), APAS We have distinguished between risk factors evident in early
(0), ART (6/40), multiple pregnancy (0) and prior HDP (0).89 pregnancy and those that emerge as pregnancy progresses;
Although some may regard universal aspirin administra- this pragmatic and comprehensive approach acknowledges
tion as preferable to a reconsideration of pre-eclampsia risk that pre-eclampsia risk may evolve and that the risk of ad-
screening, this is debated. Aspirin compliance is suboptimal, verse outcomes can be mitigated by close surveillance and
|
12 ELAWAD et al.
T A B L E 4 Risk factors for pre-eclampsia
Risk factors for pre-eclampsia

Strength of association
with pre-eclampsiaa Present at antenatal care booking Emerge as pregnancy progresses
Definite association Obesity
Prior pre-eclampsia Fetal trisomy 13
Chronic hypertension
Type-2 DM
Adolescence Severe anaemia
Type-1 DM
Probable association Overweight
Early pregnancy stage-1 hypertension
Booking prehypertensionb
Antiphospholipid antibody syndrome Any infection in current
pregnancy
Smoking (↓risk)
Obstructive sleep apnoea
Family history in mother or sister
Maternal age >40 years Excessive weight gain
Race/ethnicity: Sub-Saharan African, South Asian, Maori GDM
Past medical history Anaemia
Systemic lupus erythematosusc
Chronic kidney disease
Anaemia
Thrombophilia
Sickle cell disease
Rheumatoid arthritisc
Polycystic ovarian syndrome
Helicobacter pylori
Periodontal disease
Depression
Past obstetric history
Prior miscarriage at ≤10 weeks with same partner (↓risk)
Prior stillbirth
Placental abruption prior pregnancy
Prior preterm birth
Family history (relation unspecified)
Family history of CVD
This pregnancy
New or change in partner
Nulliparity
Multiple pregnancy
Methamphetmine use
Artificial reproductive technology Fetal trisomy 21
black
Recurrent miscarriage
Barrier contraception
13|
Risk factors for pre-eclampsia

Strength of association
with pre-eclampsiaa Present at antenatal care booking Emerge as pregnancy progresses
Possible association Urinary tract infection (current
pregnancy)
Prior HDP
Prior lower maternal birthweight or preterm birth
Abnormal uterine artery Doppler in current pregnancy
Pacific Islander
Hepatitis B infection
Previous miscarriage (timing and number unspecified)
Interpregnancy interval ≥10 years
Duration of sexual relationship <12 months
Family history in the father
Low socio-economic status
Stress
Endometriosis
Abbreviations: BMI, body mass index; CVD, cardiovascular disease; DM, diabetes mellitus; HDP, hypertensive disorder of pregnancy; HIV, human immunodeficiency virus;
SGA, small for gestational age.
a
Risk factors in the darkest shading were based on high-quality evidence. Factors in moderate shading were based on moderate-quality evidence. Factors in light shading
were based on low-quality evidence. Factors that are not shaded were based on evidence of very low quality. The following factors endorsed by CPGs are excluded, as there
was no rigorous evidence identified to evaluate their association with pre-eclampsia: ‘autoimmune disease’ as a group, elevated prepregnancy triglycerides, family history of
early-onset CVD, gestational hypertension, FGR, fetal triploidy, hyperplacentation (not otherwise specified), fetal hydrops, gestational trophoblastic disease and cocaine use.
Based on evidence of very low quality, the following factors were not supported as being associated with pre-eclampsia: prior SGA infant, vaginal bleeding in early (current)
pregnancy, fetal trisomy 18, thalassemia, HIV, tuberculosis, anxiety, malaria (current pregnancy).
b
According to American College of Cardiology/American Heart Association criteria, prehypertension is systolic BP < 120–129 mmHg with diastolic BP < 80 mmHg, and
stage-1 hypertension is systolic BP = 130–139 mmHg and/or diastolic BP = 80–89 mmHg.47
c
timed birth, either to minimise the risk of complications data processing and an awareness that pre-eclampsia risk
once pre-eclampsia develops or to prevent pre-eclampsia may evolve as pregnancy progresses, we are well placed to
from developing at term gestational age. refresh our strategy to identify, throughout pregnancy, the
The limitations of our analysis include that international women at increased risk of pre-eclampsia, and to modify
CPGs are almost exclusively from high-income countries, so their likelihood of pre-eclampsia and/or pre-eclampsia ad-
it is unsurprising that they may not address risk factors of verse outcomes, accordingly.
unique or particular importance to LMICs (e.g. malaria or
seasonality). Despite following published methodology,10 we DE TA I L S OF E T H IC S A PPROVA L
restricted our search to Medline, to focus on a peer-reviewed, Approval for the PRECISE study was obtained in King's
curated collection of citations of articles in journals approved College London (Ref: HR-17/18-7855), Aga Khan University
and indexed to include MeSH terms. We excluded small ob- Hosptial (Ref: 2018/REC-740, The Gambia Government/The
servational studies (<1000 participants), in which some risk Medical Research Council, The Gambia Joint committee
factors have been identified, from our evidence; the quality of (Ref: SCC 1619), and the Mozambique Ministry of Health,
this evidence may be improved by future systematic reviews National Bioethics Committee for Health (545/CNBS/18).
or large studies. Finally, although we used strength of associa-
tion criteria for RR and OR interchangeably, the low incidence AU T HOR C ON T R I BU T ION S
of pre-eclampsia (2%–4% of pregnancies) means that the use The project was conceived by LAM, PvD, VF, TE and GS. All
of OR is unlikely to have exaggerated the association. authors contributed to the writing and critical review of the
article, and approved the final version for publication. The
PRECISE Network contributed to the study design and pro-
5 | C ONC LUSION vided constructive challenge as part of the development of a
suite of conceptual frameworks for placental disease.
Pre-
eclampsia risk factors advocated by the CPGs were
poorly aligned with the evidence, consisting primarily of F U N DI N G I N F OR M AT ION
umbrella and other high- quality systematic reviews.11–13 This work was supported by funding from a UK Research
With the availability of multivariable prediction models in and Innovation Global Challenges Research Fund (GCRF)
early and later pregnancy, digital health technologies for GROW award (MR/P027938/1).
|
14 ELAWAD et al.
reviews and meta- a nalyses of observational studies. Ultrasound

C ON F L IC T OF I N T E R E S T S Obstet Gynecol. 2018;51(6):720–30.
None declared. Completed disclosure of interests form avail- 13. Bartsch E, Medcalf KE, Park AL, Ray JG. Clinical risk factors for
able to view online as supporting information. pre-eclampsia determined in early pregnancy: systematic review and
meta-a nalysis of large cohort studies. BMJ. 2016;353:i1753.
14. Sterne JA, Gavaghan D, Egger M. Publication and related bias in
DATA AVA I L A BI L I T Y S TAT E M E N T
meta-a nalysis: power of statistical tests and prevalence in the litera-
The data that support the findings of this study are available ture. J Clin Epidemiol. 2000;53(11):1119–29.
from the corresponding author upon reasonable request. 15. Colditz GA, Atwood KA, Emmons K, Monson RR, Willett WC,
Trichopoulos D, et al. Harvard report on cancer prevention vol-
ORC I D ume 4: Harvard Cancer Risk Index. Risk Index Working Group,
Harvard Center for Cancer Prevention. Cancer Causes Control.
Marcus Green https://orcid.org/0000-0002-4561-8256
2000;11(6):477–88.
Asma Khalil https://orcid.org/0000-0003-2802-7670 16. Rubinstein ML, Kraft CS, Parrott JS. Determining qualitative effect
Mai-Lei W. Kinshella https://orcid. size ratings using a likelihood ratio scatter matrix in diagnostic test
org/0000-0001-5846-3014 accuracy systematic reviews. Diagnosis. 2018;5(4):205–14.
Hiten D. Mistry https://orcid.org/0000-0003-2564-7348 17. Viera AJ. Odds ratios and risk ratios: what's the difference and why
does it matter? South Med J. 2008;101(7):730–4.
Marie-Laure Volvert https://orcid.
18. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al.
org/0000-0002-0527-4145 GRADE guidelines: 1. Introduction-GRADE evidence profiles and
Peter von Dadelszen https://orcid. summary of findings tables. J Clin Epidemiol. 2011;64(4):383–94.
org/0000-0003-4136-3070 19. Iorio A, Spencer FA, Falavigna M, Alba C, Lang E, Burnand B, et al.
Laura A. Magee https://orcid.org/0000-0002-1355-610X Use of GRADE for assessment of evidence about prognosis: Rating
confidence in estimates of event rates in broad categories of patients.
BMJ. 2015;350:h870.
R EFER ENCES 20. Schünemann HJ, Cuello C, Akl EA, Mustafa RA, Meerpohl JJ, Thayer
1. Mol BWJ, Roberts CT, Thangaratinam S, Magee LA, de Groot CJM, K, et al. GRADE guidelines: 18. How ROBINS-I and other tools to
Hofmeyr GJ. Pre-eclampsia. Lancet. 2016;387(10022):999–1011. assess risk of bias in nonrandomized studies should be used to rate
2. World Health Organization. WHO recommendations on antenatal the certainty of a body of evidence. J Clin Epidemiol. 2019;111:105–14.
care for a positive pregnancy experience [Internet]. Geneva. World 21. World Health Organization. WHO recommendations for prevention
Health Organization; 2016 [cited 2021 Oct 20]. Available from: and treatment of pre-eclampsia and eclampsia [Internet]. Geneva.
https://www.who.int/publications/i/item/9789241549912. World Health Organization; 2011 [cited 2019 Oct 31]. Available from:
3. Rolnik DL, Wright D, Poon LC, O'Gorman N, Syngelaki A, de Paco http://apps.who.int/iris/bitstream/handle/10665/4 4703/9789241548
Matallana C, et al. Aspirin versus placebo in pregnancies at high risk 335_eng.pdf?sequence=1
for preterm preeclampsia. N Engl J Med. 2017;377:613–22. 22. World Health Organization. WHO recommendation: Calcium sup-
4. Poon LC, Shennan A, Hyett JA, Kapur A, Hadar E, Divakar H, et al. plementation during pregnancy for the prevention of pre-eclampsia
The International Federation of Gynecology and Obstetrics (FIGO) and its complications [Internet]. Geneva. World Health Organization;
initiative on pre- eclampsia: a pragmatic guide for first- t rimester 2018 [cited 2019 Oct 31]. Available from: https://apps.who.int/iris/
screening and prevention. Int J Gynaecol Obstet. 2019;145(suppl bitst r eam/handl e /10665/ 2 7723 5 /97892 41550 4 51- e ng.pdf?seque
1):1–33. nce=1&isAllowed=y
5. O’Gorman N, Wright D, Poon LC, Rolnik DL, Syngelaki A, Wright 23. World Health Organization. WHO recommendations Drug treat-
A, et al. Accuracy of competing-risks model in screening for pre- ment for severe hypertension in pregnancy [Internet]. Geneva. World
eclampsia by maternal factors and biomarkers at 11–13 weeks' gesta- Health Organization; 2018 [cited 2019 Oct 31]. Available from: https://
tion. Ultrasound Obstet Gynecol. 2017;49(6):751–5. apps.who.int/iris/bitstream/handle/10665/277234 /97892415504 37-
6. Scott G, Gillon TE, Pels A, von Dadelszen P, Magee LA. Guidelines— eng.pdf?sequence=1&isAllowed=y
similarities and dissimilarities: a systematic review of international 24. World Health Organization. WHO recommendations: Policy of in-
clinical practice guidelines for pregnancy hypertension. Am J Obstet terventionist versus expectant management of severe pre-eclampsia
Gynecol. 2020; 26(2S):S1222–S1236. before term [Internet]. Geneva. World Health Organization; 2018
7. von Dadelszen P, Flint-O’Kane M, Poston L, Craik R, Russell D, Tribe [cited 2019 Oct 31] Available from: https://apps.who.int/iris/bitst
RM, et al. The PRECISE (PREgnancy Care Integrating translational ream/handle/10665/277236/97892415504 44-eng.pdf?ua=1
Science, Everywhere) Network's first protocol: deep phenotyping in 25. Lowe SA, Bowyer L, Lust K, McMahon L, Morton MR, North RA,
three sub-Saharan African countries. Reprod Health. 2020;17(suppl Peach MJ, Said JM. Guideline for the Management of Hypertensive
1):51. https://doi.org/10.1186/s12978-020-0872-9 Disorders of Pregnancy. [Internet]. Society of Obstetric Medicine
8. Gillon TER, Pels A, Von Dadelszen P, MacDonell K, Magee LA. of Australia and New Zealand; 2014 [cited 2019 Oct 31]. Available
Hypertensive disorders of pregnancy: a systematic review of inter- from: https://www.somanz.org/content/uploads/2020/07/HTguidelin
national clinical practice guidelines. PLoS One. 2014;9(12):e113715. eupdatedJune2015.pdf
https://doi.org/10.1371/journa l.pone.0113715 26. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomstrom-
9. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder Lundqvist C, Cifkova R, De Bonis M, et al. 2018 ESC Guidelines for
G, et al. Agree Next Steps Consortium. AGREE II: advancing guide- the management of cardiovascular diseases during pregnancy: The
line development, reporting and evaluation in health care. J Clin Task Force for the Management of Cardiovascular Diseases during
Epidemiol. 2010;63(12):1308–11. Pregnancy of the European Society of Cardiology. Eur Heart J.
10. Hiatt RA, Porco TC, Liu F, Balke K, Balmain A, Barlow J, et al. A 2018;39(34):3165–241.
multilevel model of postmenopausal breast cancer incidence. Cancer 27. Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP,
Epidemiol Biomarkers Prev. 2014;23(10):2078–92. Saito S, et al. ISSHP. Hypertensive disorders of pregnancy: ISSHP
11. Townsend R, Khalil A, Premakumar Y, Allotey J, Snell KIE, Chan classification, diagnosis & management recommendations for inter-
C, et al. Prediction of pre-eclampsia: review of reviews. Ultrasound national practice. Hypertension. 2018;72(1):24–43.
Obstet Gynecol. 2019;54(1):16–27. 28. Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P, Canadian
12. Giannakou K, Evangelou E, Papatheodorou SI. Genetic and non- Hypertensive Disorders of Pregnancy (HDP) Working Group.
genetic risk factors for pre-eclampsia: umbrella review of systematic
15 |
Diagnosis, evaluation, and management of the hypertensive disorders Therapie [internet]. Germany. Deutsche Gesellschaft Fur Gynakologie
of pregnancy. Pregnancy Hypertens. 2014;4(2):105–45. und Geburtshilfe; 2019 [cited 2019 Oct 31]. Available from: https://
29. Butalia S, Audibert F, Côté A, Firoz T, Logan AG, Magee LA, www.awmf.org/upload s/tx_szleit linien/015- 018l_S2k_Diagnostik_
et al. Hypertension Canada's 2018 Guidelines for the Management of Therapie_hyper tensiver_Schwa ngerschaftserkra nkungen_2019- 07.
Hypertension in Pregnancy. Can J Cardiol. 2018;34(5):526–31. pdf
30. The American College of Obstetricians and Gynaecologists. ACOG 41. National Institute for Health and Care Excellence. Hypertension in
Practice Bulletin No. 202: gestational hypertension and preeclamp- pregnancy: diagnosis and management (NG133) [internet]. London:
sia. Clinical management guidelines for obstetrician-g ynecologists. National Institute for Health and Care Excellence; 2019 [cited 2019
Obstet Gynecol. 2019;133(1):e1– 25. https://doi.org/10.1097/ Oct 31](1). Available from: http://www.nice.org.uk/guida nce/cg107
AOG.000000 00000 03018 %5Cnht t ps://www.dovepress.com/getfi le.php?fileI D =7818%5Cnht
31. The American College of Obstetricians and Gynecologists. ACOG tp://www.ijgo.org/article/S0020-7292(02)80002-9/abstract
Practice Bulletin No. 203: chronic hypertension in pregnancy. Clinical 42. Wielgos M, Bomba-Opon D, Breborowicz GH, Czajkowski K, Debski
management guidelines for obstetrician-g ynecologists. Obstet Gynecol. R, Leszczynska-Gorzelak B, et al. Recommendations of the Polish
2019;133(1):e26–50. https://doi.org/10.1097/AOG.0000000000003020 Society of Gynecologists and Obstetricians regarding caesarean
32. The American College of Obstetricians and Gynecologists. ACOG sections. Ginekol Pol. 2018;89(11):644– 57. https://doi.org/10.5603/
Committee Opinion Number 767: emergent therapy for acute-onset, GP.a2018.0110
severe hypertension during pregnancy and the postpartum pe- 43. Ministry of Health. Diagnosis and treatment of hypertension and pre-
riod. Obstet Gynecol. 2019;133(2):e174–80. https://doi.org/10.1097/ eclampsia in pregnancy in New Zealand: a clinical practice guideline
AOG.000000 00000 03075 [internet]. Wellington. Ministry of Health; 2018 [cited 2019 Oct 31].
33. Sociedade Brasileira de Cardiologia. 7th Brazilian Guideline of Available from: https://www.health.govt.nz/system/files/documents/
Arterial Hypertension [Internet]. Brazil: Sociedade Brasileira de public ation s/diagno sis-a nd-t reat m ent-of-hyper t ension-a nd-pre-
Cardiologia; 2016 [cited 2019 Oct 31]. Available from: http://publi eclampsia-in-pregna ncy-in-new-zealand-v3.pdf
cacoes.cardiol.br/2014/diretr izes/2016/05_HIPERTENSAO_ARTER 4 4. Ben Temime R, Boudaya F, Ouerdiane N, Mrazguia C, Ayachi A,
IAL_INGLES.pdf Kehila M, et al. Recommandations STGO: Troubles Hypertensifs de
34. Mounier- Vehier C, Amar J, Boivin J- M, Denolle T, Fauvel J- P, la Grossesse [Internet]. Tunisia. La Société Tunisienne de Gynécologie
Plu-Bureau G, et al. Hypertension and pregnancy: expert consen- Obstétrique; 2016 [cited 2019 Oct 31] Available from: https://www.
sus statement from the French Society of Hypertension, an affil- stgo.org.tn/index.php/ressources/recommandat ions-r pc
iate of the French Society of Cardiology. Fundam Clin Pharmacol. 45. Duckitt K, Harrington D. Risk factors for pre- eclampsia at an-
2017;31(1):83–103. tenatal booking: Systematic review of controlled studies. BMJ.
35. Institute of Obstetricians and Gynaecologists Royal College of 2005;330(7491):565–7.
Physicians of Ireland, Clinical Strategy and Programmes Division 46. Conde-Agudelo A, Belizán JM. Risk factors for pre-eclampsia in
Health Service Executive. Clinical Practice Guideline The a large cohort of Latin American and Caribbean women. BJOG.
Management of Hypertension in Pregnancy [Internet]. Ireland: 2000;107(1):75–83.
Institute of Obstetricians and Gynaecologists Royal College of 47. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison
Physicians of Ireland; 2016. [cited 2019 October 31]. Available Himmelfarb C, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/
from: https://rcpi-live-cdn.s3.amazonaws.com/wp-content/uploa ASH/ASPC/NMA/PCNA guideline for the prevention, detection, eval-
ds/2021/12/Hyper tensionGuideline.pdf uation, and management of high blood pressure in adults: a report of
36. Institute of Obstetricians and Gynaecologists Royal College of Physicians the American College of Cardiology/American Heart Association Task
of Ireland, Clinical Strategy and Programmes Division Health Service Force on clinical practice guidelines. Hypertension. 2018;71(6):1269–
Executive. Clinical practice guideline the diagnosis and management 324. https://doi.org/10.1161/HYP.0000000000000066
of severe pre-eclampsia and eclampsia [Internet] Ireland: Institute of 48. Boafor TK, Olayemi E, Galadanci N, Hayfron-Benjamin C, Dei-
Obstetricians and Gynaecologists Royal College of Physicians of Ireland; Adomakoh Y, Segbefia C, et al. Pregnancy outcomes in women with
2016 [cited 2019 Oct 31]. Available from: https://www.hse.ie/eng/servi sickle-cell disease in low and high income countries: a systematic re-
ces/public ations/clinic al-strategy-a nd-progra mmes/d iagnosis-a nd- view and meta-a nalysis. BJOG. 2016;123(5):691–8.
management-of-pre-eclampsia-and-eclampsia.pdf 49. Grigoriadis S, Graves L, Peer M, Mamisashvili L, Tomlinson G, Vigod
37. Nederlandse Vereniging voor Obstetrie en Gynaecologie. SN, et al. Maternal anxiety during pregnancy and the association with
Hypertensieve aandoeningen in de zwangerschap [Internet] Utrecht: adverse perinatal outcomes: systematic review and meta-a nalysis. J
Nederlandse Vereniging voor Obstetrie en Gynaecologie; 2011 [cited Clin Psychiatry. 2018;79(5):17r12011.
2019 Oct 31]. Available from: https://www.internisten.nl/sites/inter 50. Yan L, Jin Y, Hang H, Yan B. The association between urinary tract
nisten.nl/files/uploads/CV/Mx/CVMxUs9h0bleN- QRN2Y83A/richt infection during pregnancy and preeclampsia: a meta- a nalysis.
lijn_2012_-Hypertensieve-aandoeningen-in-de-zwangerschap.pdf. Medicine (Baltimore). 2018;97(36):e12192.
38. NVOG Otterlo Werkgroep. Addendum bij multidisciplinaire richtlijn 51. Li L, Tan J, Liu L, Li J, Chen G, Chen M, et al. Association between
Hypertensieve aandoeningen in de zwangerschap uit 2011 [internet]. H. pylori infection and health outcomes: an umbrella review of sys-
Utrecht: Nederlandse Vereniging voor Obstetrie en Gynaecologie; tematic reviews and meta-a nalyses. BMJ Open. 2020;10(1):e031951.
2014 [cited 2019 Oct 31]. Available from: https://www.nvog.nl/wp- https://doi.org/10.1136/bmjopen-2019- 031951
content/upload s/2018/02/Addendum-Hyper t ensie ve-a ando e ning 52. Meazaw MW, Chojenta C, Muluneh MD, Loxton D. Systematic and
en-u itga ngsvra gen-bloedd ruk-meten-en-signi f icante-protei nurie - meta-a nalysis of factors associated with preeclampsia and eclampsia
bij-rl-hypertensieve-aandoeningen-2014-2 .pdf in sub-Saharan Africa. PLoS One. 2020;15(8):e0237600. https://doi.
39. Nederlandse Vereniging voor Obstetrie en Gynaecologie (NVOG). org/10.1371/journa l.pone.0237600
Wat is de rol van acetylsalicylzuur, gestart ≤16 weken amenorroeduur, 53. Van Oostwaard MF, Langenveld J, Schuit E, Papatsonis DNM,
ter preventie van pre-eclampsie bij zwangere vrouwen? (behorende Brown MA, Byaruhanga RN, et al. Recurrence of hypertensive dis-
bij de richtlijn Hypertensieve aandoeningen in de Zwangerschap) orders of pregnancy: an individual patient data metaanalysis. Am J
[internet]. Nederlandse Vereniging voor Obstetrie en Gynaecologie Obstet Gynecol. 2015;212(5):624.e1–624.e17. https://doi.org/10.1016/j.
(NVOG); 2019 [cited 2019 Oct 31]. Available from: https://www.nvog. ajog.2015.01.009
nl/wp-content/upload s/2019/10/NVOG-module-Acetylsalic ylzuu r- 54. Grønvik T, Fossgard Sandøy I. Complications associated with adoles-
okt-2019.pdf cent childbearing in Sub-Saharan Africa: a systematic literature re-
40. Deutsche Gesellschaft Fur Gynakologie und Geburtshilfe. view and meta-a nalysis. PLoS One. 2018;13(9):e0204327. https://doi.
Hypertensive Schwangerschaftserkrankungen: Diagnostik und org/10.1371/journa l.pone.0204327
|
16 ELAWAD et al.
55. Lalani S, Choudhry AJ, Firth B, Bacal V, Walker M, Wen SW, 73. Nakagawa K, Lim E, Harvey S, Miyamura J, Juarez DT. Racial/ethnic
et al. Endometriosis and adverse maternal, fetal and neonatal disparities in the association between preeclampsia risk factors and
outcomes, a systematic review and meta- a nalysis. Hum Reprod. preeclampsia among women residing in Hawaii. Matern Child Health
2018;33(10):1854–65. J. 2016;20(9):1814–24.
56. Di Mascio D, Saccone G, Bellussi F, Vitagliano A, Berghella V. Type 74. Chen C, Grewal J, Betran AP, Vogel JP, Souza JP, Zhang J. Severe
of paternal sperm exposure before pregnancy and the risk of pre- anemia, sickle cell disease, and thalassemia as risk factors for hyper-
eclampsia: a systematic review. Eur J Obstet Gynecol Reprod Biol. tensive disorders in pregnancy in developing countries. Pregnancy
2020;251:246–53. Hypertens. 2018;13:141–7.
57. Shiadeh MN, Riahi SM, Khani S, Alizadeh S, Hosseinzadeh R, 75. Anderson NH, Sadler LC, Stewart AW, Fyfe EM, McCowan LME.
Hasanpour AH, et al. Human immunodeficiency virus and risk of Ethnicity, body mass index and risk of pre-eclampsia in a mul-
pre-eclampsia and eclampsia in pregnant women: a meta-a nalysis on tiethnic New Zealand population. Aust N Z J Obstet Gynaecol.
cohort studies. Pregnancy Hypertension. 2019;17:269–75. 2012;52(6):552–8.
58. Vestgaard M, Sommer MC, Ringholm L, Damm P, Mathiesen ER. 76. Sepidarkish M, Almasi-Hashiani A, Maroufizadeh S, Vesali S, Pirjani
Prediction of preeclampsia in type 1 diabetes in early pregnancy by R, Samani RO. Association between previous spontaneous abortion
clinical predictors: a systematic review. J Matern Fetal Neonatal Med. and pre-eclampsia during a subsequent pregnancy. Int J Gynecol
2018;31(14):1933–9. Obstet. 2017;136(1):83– 6.
59. Ren M, Li H, Cai W, Niu X, Ji W, Zhang Z, et al. Excessive gestational 77. Ticconi C, Pietropolli A, Specchia M, Nicastri E, Chiaramonte C,
weight gain in accordance with the IOM criteria and the risk of hy- Piccione E, et al. Pregnancy-related complications in women with
pertensive disorders of pregnancy: a meta-a nalysis. BMC Pregnancy recurrent pregnancy loss: a prospective cohort study. J Clin Med.
Childbirth. 2018;18(1):281. 2020;9(9):2833.
60. Wang X, Bai T, Liu S, Pan H, Wang B. Association between thrombo- 78. Gong J, Savitz DA, Stein CR, Engel SM. Maternal ethnicity and pre-
philia gene polymorphisms and preeclampsia: a meta-a nalysis. PLoS eclampsia in New York City, 1995-2003. Paediatr Perinat Epidemiol.
One. 2014;9(6):e100789. https://doi.org/10.1371/journa l.pone.0100789 2012;26(1):45–52.
61. Young MF, Oaks BM, Tandon S, Martorell R, Dewey KG, Wendt AS. 79. Gorman MC, Orme KS, Nguyen NT, Kent EJ, Caughey AB. Outcomes
Maternal hemoglobin concentrations across pregnancy and maternal in pregnancies complicated by methamphetamine use. Am J Obstet
and child health: a systematic review and meta-a nalysis. Ann N Y Gynecol. 2014;211(4):429.e1–7.
Acad Sci. 2019;1450(1):47–68. 80. Defant J, Gambello MJ, Monga M, Langlois PH, Noblin SJ, Vidaeff
62. á Rogvi R, Forman JL, Damm P, Greisen G. Women born preterm or AC. Fetal trisomy 21 and the risk of preeclampsia. J Matern Fetal
with inappropriate weight for gestational age are at risk of subsequent Neonatal Med. 2010;23(1):55–9.
gestational diabetes and pre-eclampsia. PLoS One. 2012;7(3):e34001. 81. Dotters-Katz SK, Humphrey WM, Senz KL, Lee VR, Shaffer BL,
https://doi.org/10.1371/journa l.pone.0034001 Kuller JA, et al. Trisomy 13 and the risk of gestational hypertensive
63. Bilano VL, Ota E, Ganchimeg T, Mori R, Souza JP. Risk factors of disorders: a population-based study. J Matern Fetal Neonatal Med.
pre-eclampsia/eclampsia and its adverse outcomes in low-and 2018;31(15):1951–5.
middle-income countries: a WHO secondary analysis. PLoS One. 82. Dotters-Katz SK, Senz K, Humphrey WM, Lee VR, Caughey AB. 126:
2014;9(3):e91198. https://doi.org/10.1371/journa l.prone.0091198 Trisomy 18 pregnancies: is there an increased maternal risk? Am J
6 4. Aljary H, Czuzoj- Shulman N, Spence AR, Abenhaim HA. Obstet Gynecol. 2017;216(1):S88–9.
Pregnancy outcomes in women with rheumatoid arthritis: a retro- 83. Gebremedhin AT, Regan AK, Ball S, Betrán AP, Foo D, Gissler M,
spective population-based cohort study. J Matern Neonatal Med. et al. Interpregnancy interval and hypertensive disorders of preg-
2020;33(4):618–24. nancy: a population-based cohort study. Paediatr Perinat Epidemiol.
65. Bandoli G, Lindsay S, Johnson DL, Kao K, Luo Y, Chambers CD. 2021;35(4):404–14.
Change in paternity and select perinatal outcomes: causal or con- 84. Rasmussen S, Ebbing C, Irgens LM. Predicting preeclampsia from a
founded? J Obstet Gynaecol. 2012;32(7):657–62. history of preterm birth. PLoS One. 2017;12(7):e0181016. https://doi.
66. Breathett K, Muhlestein D, Foraker R, Gulati M. Differences in pre- org/10.1371/journa l.pone.0181016
eclampsia rates between African American and caucasian women: 85. Reddy M, Rolnik DL, Harris K, Li W, Mol BW, Da Silva CF, et al.
trends from the National Hospital Discharge Survey. J Women's Heal Challenging the definition of hypertension in pregnancy: a retrospec-
(Larchmt). 2014;23(11):886–93. tive cohort study. Am J Obstet Gynecol. 2020;222(6):606.e1–606.e21.
67. Choe SA, Min HS, Cho S. The income-based disparities in preeclamp- https://doi.org/10.1016/j.ajog.2019.12.272
sia and postpartum hemorrhage: a study of the Korean National 86. Smits LJM, North RA, Kenny LC, Myers J, Dekker GA, McCowan
Health Insurance cohort data from 2002 to 2013. Springerplus. LME. Patterns of vaginal bleeding during the first 20 weeks of preg-
2016;5(1): 895. https://doi.org/10.1186/s40064-016-2620-8 nancy and risk of pre-eclampsia in nulliparous women: results from
68. North RA, McCowan LME, Dekker GA, Poston L, Chan EHY, the SCOPE study. Acta Obstet Gynecol Scand. 2012;91(11):1331–8.
Stewart AW, et al. Clinical risk prediction for pre-eclampsia in nul- 87. Kalaitzopoulos D- R , Chatzistergiou K, Amylidi A- L , Kokkinidis
liparous women: development of model in international prospective DG, Goulis DG. Effect of methamphetamine hydrochloride on preg-
cohort. BMJ. 2011;342:d1875. nancy outcome: a systematic review and meta-a nalysis. J Addict Med.
69. Serrano NC, Quintero-Lesmes DC, Dudbridge F, Leon LJ, Hingorani 2018;12(3):220–6.
AD, Williams DJ, et al. Family history of pre-eclampsia and cardio- 88. Poon LC, Wright D, Thornton S, Akolekar R, Brocklehurst P,
vascular disease as risk factors for pre-eclampsia: the GenPE case- Nicolaides KH. Mini-combined test compared with NICE guide-
control study. Hypertens Pregnancy. 2020;39(1):56–63. lines for early risk-assessment for pre-eclampsia: the SPREE diag-
70. Boyd HA, Tahir H, Wohlfahrt J, Melbye M. Associations of personal nostic accuracy study. Effic Mech Eval. 2020;7(8):1–156. https://doi.
and family preeclampsia history with the risk of early-, intermediate- org/10.3310/eme07080
and late-onset preeclampsia. Am J Epidemiol. 2013;178(11):1611–9. 89. Antwi E, Amoakoh-Coleman M, Vieira DL, Madhavaram S, Koram
71. Dennis EM, Hao Y, Tamambang M, Roshan TN, Gatlin KJ, Bghigh KA, Grobbee DE, et al. Systematic review of prediction models for
H, et al. Tuberculosis during pregnancy in the United States: ra- gestational hypertension and preeclampsia. PLoS One. 2020;15(4):1–
cial/ethnic disparities in pregnancy complications and in-hospital 24. https://doi.org/10.1371/journa l.pone.0230955
death. PLoS One. 2018;13(3):e0194836. https://doi.org/10.1371/journ 90. Abheiden CN, van Reuler AV, Fuijkschot WW, de Vries JI, Thijs A,
al.pone.0194836 de Boer MA Aspirin adherence during high-risk pregnancies, a ques-
72. Khalil A, Rezende J, Akolekar R, Syngelaki A, Nicolaides KH. tionnaire study. Pregnancy Hypertens. 2016;6(4):350–5.
Maternal racial origin and adverse pregnancy outcome: a cohort 91. Hastie R, Tong S, Wikström A- K, Sandström A, Hesselman
study. Ultrasound Obstet Gynecol. 2013;41(3):278–85. S, Bergman L. Aspirin use during pregnancy and the risk of
17 |
bleeding complications: a Swedish population-based cohort study. Am
J Obstet Gynecol. 2021;224(1):95.e1–95.e12. https://doi.org/10.1016/j.
How to cite this article: Elawad T, Scott G, Bone JN,
ajog.2020.07.023
Elwell H, Lopez CE, Filippi V, et al. the PRECISE
NetworkRisk factors for pre-eclampsia in clinical
S U PP ORT I N G I N F OR M AT ION practice guidelines: Comparison with the evidence.
Additional supporting information can be found online BJOG. 2022;00:1–17. https://doi.org/10.1111/1471-
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Risk factors for pre-­eclampsia in clinical practice guidelines:

Terteel Elawad1,2 | Georgia Scott1,3 | Jeffrey N. Bone4,5 | Helen Elwell6 |

Terteel Elawad and Georgia Scott Shared first authorship.

BJOG: Int J Obstet Gy. 2022;00:1–17. ﻿ wileyonlinelibrary.com/journal/bjo | 1

1 | I N T RODUC T ION 2 | M ET HODS

Pre-­eclampsia complicates 2%–­4% of pregnancies world- 2.1 | Systematic review of CPGs

Initially High Moderate Low Very low

Strength of (↑risk) (↓ risk) LR+ LR−

High (N = 4) Moderate (N = 11) Low (N = 35) Very low (N = 18)

Strength of Definite CPGs Obesity Prior pre-­eclampsia Adolescence –­

T A B L E 3 Risk factors for pre-­eclampsia

Conceptual framework Clinical practice guidelines6

Conceptual framework Clinical practice guidelines6

Conceptual framework Clinical practice guidelines6

Conceptual framework Clinical practice guidelines6

T A B L E 4 Risk factors for pre-­eclampsia

Risk factors for pre-­eclampsia

Risk factors for pre-­eclampsia

reviews and meta-­ a nalyses of observational studies. Ultrasound

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Risk factors for pre-eclampsia in clinical practice guidelines:

BJOG: Int J Obstet Gy. 2022;00:1–17. wileyonlinelibrary.com/journal/bjo | 1

Pre-eclampsia complicates 2%–4% of pregnancies world- 2.1 | Systematic review of CPGs

Strength of Definite CPGs Obesity Prior pre-eclampsia Adolescence –

T A B L E 3 Risk factors for pre-eclampsia

T A B L E 4 Risk factors for pre-eclampsia

Risk factors for pre-eclampsia

Risk factors for pre-eclampsia

reviews and meta- a nalyses of observational studies. Ultrasound