Final Research Plan

Hypertensive Disorders of Pregnancy: Screening

September 02, 2021

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Figure 1 is the analytic framework that depicts the three Key Questions to be addressed in the systematic review. The figure illustrates how different screening programs used to identify hypertensive disorders of pregnancy among asymptomatic pregnant individuals may reduce maternal, perinatal, and child morbidity and mortality (KQ1). Additionally, the figure depicts how effective different screening programs used to identify hypertensive disorders of pregnancy among asymptomatic pregnant individuals may be (KQ2), as well as harms that may be associated with different screening programs used to identify hypertensive disorders of pregnancy among asymptomatic pregnant individuals (KQ3).

  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 persons with hypertensive disorders of pregnancy?
  3. What are the harms of different screening programs used to identify hypertensive disorders of pregnancy?

Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.

  1. How do racism and social inequalities contribute to existing inequities in morbidity and mortality from hypertensive disorders of pregnancy? For example, what accounts for higher mortality from hypertensive disorders of pregnancy among Black compared with White populations in the United States?
  2. Are there effective interventions that could redress existing inequities in morbidity and mortality from hypertensive disorders of pregnancy? 
  3. What is the effectiveness of blood pressure self-monitoring and its potential utility in telehealth prenatal or postpartum care delivery?
  4. How are risk assessment and risk prediction tools being used in clinical practice to inform screening programs?

The Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the key questions (KQs).

Category Inclusion criteria Exclusion criteria
Populations Pregnant and postpartum persons, including those at increased risk for hypertensive disorders of pregnancy Studies limited to:
  • Pregnant persons already diagnosed with a hypertensive disorder of pregnancy (e.g., chronic hypertension, preeclampsia)
  • Nongeneralizable populations limited to select populations requiring specialized prenatal care (e.g., persons with HIV, hepatitis, renal disease, or sickle cell trait, or organ transplant recipients)
Interventions Screening programs used to identify preeclampsia and other hypertensive disorders of pregnancy over the course of pregnancy and in the postpartum period (up to 8 weeks after delivery), including studies comparing screening with different protocols in terms of:
  • Blood pressure measurement, setting (office or home), interval, frequency, or timing
  • Proteinuria assessment setting, interval, or sequence of testing
  • Personalization of screening based on risk assessment

Programs for monitoring persons with hypertensive disorders of pregnancy

  • Secondary evaluations and tests used to confirm diagnosis or assess disease severity
  • Prognostic evaluation used to inform disease management
Comparisons Usual care screening programs, as defined by the study  
Outcomes KQ1 (maternal and perinatal health outcomes):

Maternal

  • Eclamptic seizure
  • Stroke
  • Cardiomyopathy, myocardial infarction
  • Renal or hepatic injury/failure
  • Pulmonary edema, adult respiratory distress syndrome
  • Venous thromboembolism (deep vein thrombosis/pulmonary embolism)
  • Disseminated intravascular coagulation
  • Longer-term health consequences from complications of pregnancy
  • Maternal mortality

Fetal/infant

  • Preterm birth (<37 weeks): late preterm birth (34–36 weeks), moderate preterm birth, (32–34 weeks), very preterm birth (<32 weeks), extremely preterm birth (<28 weeks)
  • Gestational age at birth
  • Low birth weight (weight <2,500 g)
  • Intrauterine growth restriction/small for gestational age (<10th percentile weight for gestational age)
  • Stillbirth or neonatal mortality
  • Longer-term health consequences from complications of hypertensive disorders of pregnancy

KQ 2 (hypertensive disorders of pregnancy):

  • Gestational hypertension
  • Preeclampsia, preeclampsia with severe features
  • Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome
  • Chronic hypertension with superimposed preeclampsia
  • Timing of diagnosis

KQ 3 (harms):

  • Missed diagnosis (e.g., diagnosis timing, severity at time of diagnosis)
  • Overdiagnosis and overtreatment (e.g., increased labor induction, cesarean delivery, induced preterm birth, hypermagnesemia)
  • Mental health diagnoses or symptoms
  • Reduced quality of life
 Nonclinical health outcomes, such as length of hospital stay (without indication), intensive care unit admission, or neonatal intensive care unit admission
Setting Primary care outpatient settings for obstetric care (e.g., obstetrician-gynecologists, family physicians, certified nurse midwives)

Countries categorized as “Very High” or equivalent on the Human Development Index (as defined by the United Nations Development Programme)

 Clinics and study sites treating only high-risk maternity patients
Study Designs Randomized, controlled trials; controlled clinical trials; and nonrandomized studies comparing screening programs (e.g., comparisons over time or between settings, population cohort studies, nested case-control studies) Studies that do not represent the spectrum of disease (e.g., case-control study, editorial, narrative review, commentary, postmarketing surveillance, and case report)
Publication Dates References from the previous USPSTF review, and eligible studies identified through a bridge search  
Study Quality Good and fair quality according to USPSTF design-specific criteria Poor quality according to USPSTF design-specific criteria
Publication language English Non-English language studies

The draft Research Plan was posted on the USPSTF website for public comment from May 20, 2021, through June 16, 2021. The USPSTF received comments and questions related to the scope of the review. In response, the USPSTF modified the Research Plan to clarify the population of interest, the wording of the contextual questions, and the focus of the review on the health effects of screening in the prenatal and postpartum periods.