The impact of pre-eclampsia definitions on the identification of adverse outcome risk in hypertensive pregnancy - analyses from the CHIPS trial (Control of Hypertension in Pregnancy Study)

L A Magee¹, J Singer², T Lee³, E Rey^{4

5}, E Asztalos⁶, E Hutton⁷, M Helewa⁸, A G Logan⁹, W Ganzevoort¹⁰, R Welch¹¹, J G Thornton¹², M L Woo Kinshella¹³, M Green¹⁴, E Tsigas¹⁵, P von Dadelszen¹; CHIPS Study Group

Affiliations

¹ Department of Women and Children's Health, King's College London, London, UK.
² School of Population and Public Health, Centre for Health Evaluation and Outcome Science, Providence Health Care Research Institute, University of British Columbia, Vancouver, BC, Canada.
³ Centre for Health Evaluation and Outcome Science, Providence Health Care Research Institute, University of British Columbia, Vancouver, BC, Canada.
⁴ Department of Medicine, Université de Montreal, Montreal, QC, Canada.
⁵ Department of Obstetrics and Gynaecology, Université de Montreal, Montreal, QC, Canada.
⁶ Pediatrics, University of Toronto, Toronto, ON, Canada.
⁷ Midwifery, McMaster University, Hamilton, ON, Canada.
⁸ Obstetrics and Gynaecology, University of Manitoba, Winnipeg, MB, Canada.
⁹ Department of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ Department of Obstetrics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
¹¹ University of Plymouth, Plymouth, UK.
¹² Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK.
¹³ University of British Columbia, Vancouver, BC, Canada.
¹⁴ Action on Pre-eclampsia Charity (APEC), Evesham, UK.
¹⁵ Preeclampsia Foundation, Melbourne, FL, USA.

PMID: 33230924
DOI: 10.1111/1471-0528.16602

Randomized Controlled Trial

The impact of pre-eclampsia definitions on the identification of adverse outcome risk in hypertensive pregnancy - analyses from the CHIPS trial (Control of Hypertension in Pregnancy Study)

L A Magee et al. BJOG. 2021 Jul.

. 2021 Jul;128(8):1373-1382.

doi: 10.1111/1471-0528.16602. Epub 2021 Feb 25.

Authors

Affiliations

¹ Department of Women and Children's Health, King's College London, London, UK.
² School of Population and Public Health, Centre for Health Evaluation and Outcome Science, Providence Health Care Research Institute, University of British Columbia, Vancouver, BC, Canada.
³ Centre for Health Evaluation and Outcome Science, Providence Health Care Research Institute, University of British Columbia, Vancouver, BC, Canada.
⁴ Department of Medicine, Université de Montreal, Montreal, QC, Canada.
⁵ Department of Obstetrics and Gynaecology, Université de Montreal, Montreal, QC, Canada.
⁶ Pediatrics, University of Toronto, Toronto, ON, Canada.
⁷ Midwifery, McMaster University, Hamilton, ON, Canada.
⁸ Obstetrics and Gynaecology, University of Manitoba, Winnipeg, MB, Canada.
⁹ Department of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ Department of Obstetrics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
¹¹ University of Plymouth, Plymouth, UK.
¹² Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK.
¹³ University of British Columbia, Vancouver, BC, Canada.
¹⁴ Action on Pre-eclampsia Charity (APEC), Evesham, UK.
¹⁵ Preeclampsia Foundation, Melbourne, FL, USA.

PMID: 33230924
DOI: 10.1111/1471-0528.16602

Abstract

Objective: To examine the association between pre-eclampsia definition and pregnancy outcome.

Design: Secondary analysis of Control of Hypertension in Pregnancy Study (CHIPS) trial data.

Setting: International multicentre randomised controlled trial (RCT).

Population: In all, 987 women with non-severe non-proteinuric pregnancy hypertension.

Methods: We evaluated the association between pre-eclampsia definitions and adverse pregnancy outcomes, stratified by hypertension type and blood pressure control.

Main outcome measures: Main CHIPS trial outcomes: primary (perinatal loss or high-level neonatal care for >48 hours), secondary (serious maternal complications), birthweight <10th centile, severe maternal hypertension, delivery at <34 or <37 weeks, and maternal hospitalisation before birth.

Results: Of 979/987 women with informative data, 280 (28.6%) progressed to pre-eclampsia defined restrictively by new proteinuria, and 471 (48.1%) to pre-eclampsia defined broadly as proteinuria or one/more maternal symptoms, signs or abnormal laboratory tests. The broad (versus restrictive) definition had significantly higher sensitivities (range 62-79% versus 36-50%), lower specificities (range 53-65% versus 72-82%), and similar or higher diagnostic odds ratios and 'true-positive' to 'false-positive' ratios. Stratified analyses showed similar results. Addition of available fetoplacental manifestations (stillbirth or birthweight <10th centile) to the broad pre-eclampsia definition improved sensitivity (74-87%).

Conclusions: A broad (versus restrictive) pre-eclampsia definition better identifies women who develop adverse pregnancy outcomes. These findings should be replicated in a prospective study within routine healthcare to ensure that the anticipated increase in surveillance and intervention in a larger number of women with pre-eclampsia is associated with improved outcomes, reasonable costs and congruence with women's values.

Tweetable abstract: A broad (versus restrictive) pre-eclampsia definition better identifies the risk of adverse pregnancy outcomes.

Keywords: Definition; maternal outcome; perinatal outcome; pre-eclampsia; severe hypertension.

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References

1. Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, et al. Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension 2018;72:24-43.
1. Duffy J, Cairns AE, Richards-Doran D, van 't Hooft J, Gale C, Brown M, et al. A core outcome set for pre-eclampsia research: an international consensus development study. BJOG 2020;127:1516-26.
1. Boriboonhirunsarn D, Pradyachaipimol A, Viriyapak B. Incidence of superimposed preeclampsia among pregnant Asian women with chronic hypertension. Hypertens Pregnancy 2017;36:226-31.
1. Chappell LC, Enye S, Seed P, Briley AL, Poston L, Shennan AH. Adverse perinatal outcomes and risk factors for preeclampsia in women with chronic hypertension: a prospective study. Hypertension 2008;51:1002-9.
1. Moussa HN, Leon MG, Marti A, Chediak A, Pedroza C, Blackwell SC, et al. Pregnancy outcomes in women with preeclampsia superimposed on chronic hypertension with and without severe features. Am J Perinatol 2017;34:403-8.

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The impact of pre-eclampsia definitions on the identification of adverse outcome risk in hypertensive pregnancy - analyses from the CHIPS trial (Control of Hypertension in Pregnancy Study)

Affiliations

The impact of pre-eclampsia definitions on the identification of adverse outcome risk in hypertensive pregnancy - analyses from the CHIPS trial (Control of Hypertension in Pregnancy Study)

Authors

Affiliations

Abstract

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Other Literature Sources