Screening for Hypertensive Disorders of Pregnancy: An Evidence Update for the U.S. Preventive Services Task Force

Project Summary Title and Description

Title
Screening for Hypertensive Disorders of Pregnancy: An Evidence Update for the U.S. Preventive Services Task Force
Description
Objective: We conducted this comparative effectiveness review to support the U.S. Preventive Services Task Force in updating its recommendation on Preeclampsia Screening. The review aim was to compare different approaches to screening for hypertensive disorders of pregnancy including preeclampsia. Data Sources: We performed comprehensive searches of MEDLINE, PubMed (publisher-supplied only), Embase, and the Cochrane Collaboration Registry of Controlled Trials for studies published between January 1st, 2014 and January 4th, 2022. A research librarian developed and executed the search strategy. Studies included in the prior review to support the 2015 recommendation and studies referenced in recently published reviews were also considered for inclusion. Study Selection: We reviewed 6,316 abstracts and assessed 82 full-text articles against predefined inclusion and exclusion criteria. Studies considered for inclusion were randomized controlled trials and non-randomized studies of interventions (NRSI) comparing screening interventions conducted with pregnant and postpartum people, including those at increased risk for hypertensive disorders of pregnancy. Interventions and comparisons of interest included: blood pressure measurement setting (office or home), interval, frequency, or timing; proteinuria assessment setting, interval, or sequence of testing; and personalization of screening based on risk assessment. Data Analysis: We conducted dual independent critical appraisal of all included studies and extracted all important study details and outcomes from fair- and good-quality studies. We narratively synthesized results by key question and type of screening intervention. We graded the overall strength of evidence as high, moderate, low, or insufficient based on criteria adapted from the Evidence-based Practice Center program. Results: Five fair-quality randomized controlled trials and one fair-quality NRSI with a historical control were included. Three types of screening strategies were compared with usual screening programs: screening programs that incorporated self-measurement of blood pressure (2 studies, N= 2,521), a reduced prenatal visit schedule for people at low risk for complications of hypertensive disorders of pregnancy (3 studies, N= 5,203), and protein urine screening provided only when indicated rather than at every prenatal visit (1 study, N = 2,441). No studies were designed to test screening interventions focused on populations with the highest risks for hypertensive disorders of pregnancy and adverse pregnancy-related health outcomes. One trial (N = 2,441) incorporated home blood pressure measurement into prenatal care and reported health outcomes. Similar proportions of maternal complications related to hypertensive disorders of pregnancy were seen in the home measurement group (15/1209; 1.2%) as in the usual care group (19/1209; 1.6%). The confidence interval for the relative risk spanned null (RR 0.79 [95% CI, 0.40 to 1.55]). Similar proportions of intrauterine growth restriction occurred in the intervention group (104/1249, 8.3%) compared with the control group (87/1235, 7.0%), and the confidence interval again spanned null (adjusted RR 1.15 [95% CI, 0.87 to 1.53]). The trial also did not report a difference in the timing of detection of high blood pressure. Increased anxiety, a potential harm of home blood pressure measurement, was assessed in two trials and was not associated with the intervention. Three trials published in 1996 and 1997 compared reduced prenatal visit schedules, which result in fewer antenatal blood pressure assessments, to usual care in populations at low risk for complications. Although the power to detect differences was limited for most outcomes, overall having fewer prenatal visits was not associated with better or worse pregnancy outcomes based on two trials. A large US trial (N= 2,328) including mostly White participants (81%) and a similarly sized UK trial (N= 2,794) where approximately one-third of participants belonged to an “ethnic minority” reported no evidence of differences in preeclampsia diagnoses (RR 0.94 [95% CI, 0.78 to 1.14] and RR 0.85 [95% CI, 0.35 to 2.04], respectively) or in maternal or perinatal health outcomes associated with a reduced visit schedule, although many of the outcomes were uncommon, which limited precision and the ability to rule out differences in serious outcomes. A small US trial (N = 81) was very underpowered for assessing differences between groups for serious health outcomes; few harms outcomes were reported. The UK trial and the small US trial assessed rates of anxiety or depression during and after pregnancy but did not find differences associated with the visit schedule. A fair-quality non-randomized study with a historical control (N = 2,441) evaluated the effect of implementing indicated instead of routine urine screening in a setting predominantly serving Hispanic/Latino people with public health insurance reported. Indicated urine screening was associated with increased risk of preterm birth compared to routine screening (RR 0.64 [95% CI, 0.45 to 0.90]), and diagnoses of hypertensive disorders of pregnancy did not differ following implementation. Limitations: There is very little evidence available to assess potential changes to clinical screening practices that could improve clinical outcomes related to hypertensive disorders of pregnancy. Only one fair-quality randomized study provided evidence on the effects of incorporating home-based blood pressure measurement to screen for hypertensive disorders of pregnancy on patient health outcomes. The included studies of reduced visit schedules provide potentially confounded tests of the effects of fewer office-based blood pressure measurements over the course of pregnancy, as a change in frequency of other tests and counseling received during visits could also influence the results. The evidence on an indicated urine screening strategy is very limited given the risks of bias inherent to historically controlled studies; reported findings may be due to factors other than the screening program. Black and American Indian/Alaska Native people, who experience the highest risks for adverse pregnancy-related health outcomes, were very underrepresented in the included studies. Conclusions: Screening for hypertensive disorders of pregnancy with standard of care office-based blood pressure measurement can identify individuals requiring further surveillance and evidence-based clinical management to decrease risks for related adverse pregnancy outcomes. Research is needed to develop and strengthen clinical screening and management, possibly incorporating telehealth, home-based blood pressure measurement, and postpartum screening. Addressing troubling and persistent health inequities related to hypertensive disorders of pregnancy among specific populations in the US – especially Black and American Indian/Alaska Native people – will require interventions at multiple levels, including policies, health systems, and clinical practices.
Attribution
Kaiser Permanente Evidence-based Practice Center
Authors of Report
Jillian T. Henderson, PhD, MPH Elizabeth M. Webber, MS Kimberly K. Vesco, MD, MPH Rachel G. Thomas, MPH
Methodology description
Systematic Review
PROSPERO
N/A
DOI
N/A
Notes
The research plan was posted for public comment and the final research plan available at https://www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/hypertensive-disorders-pregnancy-screening . Henderson JT, Webber EM, Vesco KK, Thomas RG. Screening for Hypertensive Disorders of Pregnancy: An Evidence Update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 227. AHRQ Publication No. 22-05299-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2023. The data entered retrospectively, using manual data entry into the SRDR+ extraction form
Funding Source
Agency for Healthcare Research and Quality

Key Questions

1. Default question
2. Default question
3. Default question
4. Default question
5. Default question
6. Default question
7. Default question
8. Default question
9. Default question
10. Default question
11. Default question
12. Default question
13. Default question
14. Default question
15. Default question
16. Default question
17. Default question
18. Default question
19. Default question
20. Default question
21. Default question
22. Default question
23. Default question
24. Default question
25. Default question
26. Default question
27. Default question
28. Default question
29. Default question
30. Default question
31. Default question
32. Default question
33. Default question
34. Default question
35. Default question
36. Default question
37. Default question
38. Default question
39. Default question
40. Default question
41. Default question
42. Default question
43. Default question
44. Default question
45. Default question
46. Default question
47. Default question
48. Default question
49. Default question
50. Default question
51. Default question
52. Default question
53. Default question
54. Default question
55. Default question
56. Default question
57. Default question
58. Default question
59. Default question
60. Default question
61. Default question
62. Default question
63. Default question
64. Default question
65. Default question
66. Default question
67. Default question
68. Default question
69. Default question
70. Default question
71. Default question
72. Default question
73. Default question
74. Default question
75. Default question
76. Default question
77. Default question
78. Default question
79. Default question
80. Default question
81. Default question
82. Default question
83. Default question
84. Default question
85. Default question
86. Default question
87. Default question
88. Default question
89. Default question
90. Default question
91. Default question
92. Default question
93. Default question
94. Default question
95. Default question
96. Default question
97. Default question
98. Default question
99. Default question
100. Default question
101. Default question
102. Default question
103. Default question
104. Default question
105. Default question
106. Default question
107. Default question
108. Default question
109. Default question
110. Default question
111. Default question
112. Default question
113. Default question
114. Default question
115. Default question
116. Default question
117. Default question
118. Default question
119. Default question
120. Default question
121. Default question
122. Default question
123. Default question
124. Default question
125. Default question
126. Default question
127. Default question
128. Default question
129. Default question
130. Default question
131. Default question
132. Default question
133. Default question
134. Default question
135. Default question
136. Default question
137. Default question
138. Default question
139. Default question
140. Default question
141. Default question
142. Default question
143. Default question
144. Default question
145. Default question
146. Default question
147. Default question
148. Default question
149. Default question
150. Default question
151. Default question
152. Default question
153. Default question
154. Default question
155. Default question
156. Default question
157. Default question
158. Default question
159. Default question
160. Default question
161. Default question
162. Default question
163. Default question
164. Default question
165. Default question
166. Default question
167. Default question
168. Default question
169. Default question
170. Default question
171. Default question
172. Default question
173. Default question
174. Default question
175. Default question
176. Default question
177. Default question
178. Default question
179. Default question
180. Default question
181. Default question
182. Default question
183. Default question
184. Default question
185. Default question
186. Default question
187. Default question
188. Default question
189. Default question
190. Default question
191. Default question
192. Default question
193. Default question
194. Default question
195. Default question
196. Default question
197. Default question
198. Default question
199. Default question
200. Default question
201. Default question
202. Default question
203. Default question
204. Default question
205. Default question
206. Default question
207. Default question
208. Default question
209. Default question
210. Default question
211. Default question
212. Default question
213. Default question
214. Default question
215. Default question
216. Default question
217. Default question
218. Default question
219. Default question
220. Default question
221. Default question
222. Default question
223. Default question
224. Default question
225. Default question
226. Default question
227. Default question
228. Default question
229. Default question
230. Default question
231. Default question
232. Default question
233. Default question
234. Default question
235. Default question
236. Default question
237. Default question
238. Default question
239. Default question
240. Default question
241. Default question
242. Default question
243. Default question
244. Default question
245. Default question
246. Default question
247. Default question
248. Default question
249. Default question
250. Default question
251. Default question
252. Default question
253. Default question
254. Default question
255. Default question
256. Default question
257. Default question
258. Default question
259. Default question
260. Default question
261. Default question
262. Default question
263. Default question
264. Default question
265. Default question
266. Default question
267. Default question
268. Default question
269. Default question
270. Default question
271. Default question
272. Default question
273. Default question
274. Default question
275. Default question
276. Default question
277. Default question
278. Default question
279. Default question
280. Default question
281. Default question
282. Default question
283. Default question
284. Default question
285. Default question
286. Default question
287. Default question
288. Default question
289. Default question
290. Default question
291. Default question
292. Default question
293. Default question
294. Default question
295. Default question
296. Default question
297. Default question
298. Default question
299. Default question
300. Default question
301. Default question
302. Default question
303. Default question
304. Default question
305. Default question
306. Default question
307. Default question
308. Default question
309. Default question
310. Default question
311. Default question
312. Default question
313. Default question
314. Default question
315. Default question
316. Default question
317. Default question
318. Default question
319. Default question
320. Default question
321. Default question
322. Default question
323. Default question
324. Default question
325. Default question
326. Default question
327. Default question
328. Default question
329. Default question
330. Default question
331. Default question
332. Default question
333. Default question
334. Default question
335. Default question
336. Default question
337. Default question
338. Default question
339. Default question
340. Default question
341. Default question
342. Default question
343. Default question
344. Default question
345. Default question
346. Default question
347. Default question
348. Default question
349. Default question
350. Default question
351. Default question
352. Default question
353. Default question
354. Default question
355. Default question
356. Default question
357. Default question
358. Default question
359. Default question
360. Default question
361. Default question
362. Default question
363. Default question
364. Default question
365. Default question
366. Default question
367. Default question
368. Default question
369. Default question
370. Default question
371. Default question
372. Default question
373. Default question
374. Default question
375. Default question
376. Default question
377. Default question
378. Default question
379. Default question
380. Default question
381. Default question
382. Default question
383. Default question
384. Default question
385. Default question
386. Default question
387. Default question
388. Default question
389. Default question
390. Default question
391. Default question
392. Default question
393. Default question
394. Default question
395. Default question
396. Default question
397. Default question
398. Default question
399. Default question
400. Default question
401. Default question
402. Default question
403. Default question
404. Default question
405. Default question
406. Default question
407. Default question
408. Default question
409. Default question
410. Default question
411. Default question
412. Default question
413. Default question
414. Default question
415. Default question
416. Default question
417. Default question
418. Default question
419. Default question
420. Default question
421. Default question
422. Default question
423. Default question
424. Default question
425. Default question
426. Default question
427. Default question
428. Default question
429. Default question
430. Default question
431. Default question
432. Default question
433. Default question
434. Default question
435. Default question
436. Default question
437. Default question
438. Default question
439. Default question
440. Default question
441. Default question
442. Default question
443. Default question
444. Default question
445. Default question
446. Default question
447. Default question
448. Default question
449. Default question
450. Default question
451. Default question
452. Default question
453. Default question
454. Default question
455. Default question
456. Default question
457. Default question
458. Default question
459. Default question
460. Default question
461. Default question
462. Default question
463. Default question
464. Default question
465. Default question
466. Default question
467. Default question
468. Default question
469. Default question
470. Default question
471. Default question
472. Default question
473. Default question
474. Default question
475. Default question
476. Default question
477. Default question
478. Default question
479. Default question
480. Default question
481. Default question
482. Default question
483. Default question
484. Default question
485. Default question
486. Default question
487. Default question
488. Default question
489. Default question
490. Default question
491. Default question
492. Default question
493. Default question
494. Default question
495. Default question
496. Default question
497. Default question
498. Default question
499. Default question
500. Default question
501. Default question
502. Default question
503. Default question
504. Default question
505. Default question
506. Default question
507. Default question
508. Default question
509. Default question
510. Default question
511. Default question
512. Default question
513. Default question
514. Default question
515. Default question
516. Default question
517. Default question
518. Default question
519. Default question
520. Default question
521. Default question
522. Default question
523. Default question
524. Default question
525. Default question
526. Default question
527. Default question
528. Default question
529. Default question
530. Default question
531. Default question
532. Default question
533. Default question
534. Default question
535. Default question
536. Default question
537. Default question
538. Default question
539. Default question
540. Default question
541. Default question
542. Default question
543. Default question
544. Default question
545. Default question
546. Default question
547. Default question
548. Default question
549. Default question
550. Default question
551. Default question
552. Default question
553. Default question
554. Default question
555. Default question
556. Default question
557. Default question
558. Default question
559. Default question
560. Default question
561. Default question
562. Default question
563. Default question
564. Default question
565. Default question
566. Default question
567. Default question
568. Default question
569. Default question
570. Default question
571. Default question
572. Default question
573. Default question
574. Default question
575. Default question
576. Default question
577. Default question
578. Default question
579. Default question
580. Default question
581. Default question
582. Default question
583. Default question
584. Default question
585. Default question
586. Default question
587. Default question
588. Default question
589. Default question
590. Default question
591. Default question
592. Default question
593. Default question
594. Default question
595. Default question
596. Default question
597. Default question
598. Default question
599. Default question
600. Default question
601. Default question
602. Default question
603. Default question
604. Default question
605. Default question
606. Default question
607. Default question
608. Default question
609. Default question
610. Default question
611. Default question
612. Default question
613. Default question
614. Default question
615. Default question
616. Default question
617. Default question
618. Default question
619. Default question
620. Default question
621. Default question
622. Default question
623. Default question
624. Default question
625. Default question
626. Default question
627. Default question
628. Default question
629. Default question
630. Default question
631. Default question
632. Default question
633. Default question
634. Default question
635. Default question
636. Default question
637. Default question
638. Default question
639. Default question
640. Default question
641. Default question
642. Default question
643. Default question
644. Default question
645. Default question
646. Default question
647. Default question
648. Default question
649. Default question
650. Default question
651. Default question
652. Default question
653. Default question
654. Default question
655. Default question
656. Default question
657. Default question
658. Default question
659. Default question
660. Default question
661. Default question
662. Default question
663. Default question
664. Default question
665. Default question
666. Default question
667. Default question
668. Default question
669. Default question
670. Default question
671. Default question
672. Default question
673. Default question
674. 1. How effective are different screening programs used to identify hypertensive disorders of pregnancy for reducing maternal and perinatal morbidity and mortality? 2. How effective are different screening programs for identifying people with hypertensive disorders of pregnancy? 3. What are the harms of different screening programs used to identify hypertensive disorders of pregnancy?

Associated Extraction Forms

Type
Standard

Associated Studies (each link opens a new tab)

Title Authors Year
Indicated vs. routine prenatal urine chemical reagent strip testing. Rhode Mary Ann, Shapiro Howard, Jones Oliver W 2007
Effect of frequency of prenatal care visits on perinatal outcome among low-risk women. A randomized controlled trial. McDuffie R S, Beck A, Bischoff K, Cross J, Orleans M 1996
Antenatal home blood pressure monitoring: a pilot randomised controlled trial. Ross-McGill H, Hewison J, Hirst J, Dowswell T, Holt A, Brunskill P, Thornton J G 2000
A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project. Sikorski J, Wilson J, Clement S, Das S, Smeeton N 1996
Evaluation of a reduced-frequency prenatal visit schedule for low-risk women at a free-standing birthing center. Walker D S, Koniak-Griffin D 1997
Effect of Self-monitoring of Blood Pressure on Diagnosis of Hypertension During Higher-Risk Pregnancy: The BUMP 1 Randomized Clinical Trial. Tucker Katherine L, Mort Sam, Yu Ly-Mee, Campbell Helen, Rivero-Arias Oliver, Wilson Hannah M, Allen Julie, Band Rebecca, Chisholm Alison, Crawford Carole, Dougall Greig, Engonidou Lazarina, Franssen Marloes, Green Marcus, Greenfield Sheila, Hinton Lisa, Hodgkinson James, Lavallee Layla, Leeson Paul, McCourt Christine, Mackillop Lucy, Sandall Jane, Santos Mauro, Tarassenko Lionel, Velardo Carmelo, Yardley Lucy, Chappell Lucy C, McManus Richard J, BUMP Investigators 2022

Downloadable Data Content

Files
  • XLSX Project Data