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USPSTF Recommendation on Screening for Hypertensive Disorders of Pregnancy

In an update of its 2017 recommendation on screening for preeclampsia, the U.S. Preventive Services Task Force (USPSTF) supports screening for hypertensive disorders in pregnant persons with blood pressure measurements throughout pregnancy (B recommendation). Low-dose aspirin (81 mg/d) is also recommended as a preventive medication after 12 weeks’ gestation in persons at high risk for preeclampsia.

Evidence Report:  The USPSTF makes its recommendation based on 6 fair-quality studies (5 trials and 1 nonrandomized study; N = 10,165) that compared changes in prenatal screening practices with usual care (routine screening at in-person office visits): “No studies addressed screening for new-onset hypertensive disorders of pregnancy in the postpartum period. One trial (n = 2,521) evaluated home blood pressure measurement as a supplement to usual care; 3 trials (total n = 5,203) evaluated reduced prenatal visit schedules. One study (n = 2,441) evaluated proteinuria screening conducted only for specific clinical indications, compared with a historical control group that received routine proteinuria screening. One additional trial (n = 80) only addressed the comparative harms of home blood pressure measurement. The studies did not report statistically significant differences in maternal and infant complications with alternate strategies compared with usual care; however, estimates were imprecise for serious, rare health outcomes. Home blood pressure measurement added to prenatal care visits was not associated with earlier diagnosis of a hypertensive disorder of pregnancy (104.3 vs 106.2 days), and incidence was not different between groups in 3 trials of reduced prenatal visit schedules. No harms of the different screening strategies were identified.”

Editorial 1: “To date, national guidelines for [hypertensive disorders of pregnancy (HDP)] screening have focused on [blood pressure (BP)] measurements and maternal risk factor assessment due to proven efficacy and lack of harm,” editorialists write. “Multimodal assessments (eg, biomarkers, uterine artery Doppler) have not been universally adopted due to the needed increased resources, lack of diversity in validation studies, and lack of cost-effectiveness data. The key to improving HDP screening and prevention will rely on correctly classifying HDP subtypes and their underlying causes. Many varied and overlapping phenotypes for preeclampsia have been described, all likely arising from different pathophysiologic pathways. New technologies, including machine learning, as well as omics data, including genomics, transcriptomics, proteomics, and metabolomics, have been increasing understanding of preeclampsia mechanisms. The future of preeclampsia screening and prevention should be focused on precision medicine to provide tailored and effective treatment strategies. Lastly, socioeconomic barriers to care need to be explored. Obstetricians should consider multimodal care implementation to include midwives, nurses, emergency physicians, and community-based programs to increase care to all pregnant persons. Standardized safety bundles within institutions can ensure that all patients receive safe and equitable care. Improving outcomes will require us to listen to our patients and those close to them.”

Editorial 2: “Pregnancy is a window of opportunity to influence current and future life course, not just of the individual, but also of the fetus(es), other children, and family,” editorialists write. “Poor maternal health reflects inaction and reluctance as a nation to prioritize wellness and health for all. We cannot ignore the rising maternal morbidity and mortality rates and must recognize this public health crisis that is affecting us all. The onus is on all of us. To the scientific community, research should not be an afterthought for pregnant-capable and pregnant persons, because through research we can advance the clarity and implementation of the care recommendations. Finally, it is imperative that the medical community, especially internists, take more responsibility in caring for pregnant individuals’ immediate and long-term health: it takes a collective village, acting with purpose and urgency.”

Source: JAMA