The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community

TLDR

Pre‑eclampsia is a leading cause of maternal and fetal morbidity and mortality, responsible for a large proportion of stillbirths and severe obstetric complications, yet no uniform community screening guidelines exist. The authors aimed to develop a community guideline (PRECOG) to standardise screening, risk assessment, and early referral for pre‑eclampsia. PRECOG was created following NICE guideline development standards, endorsed by major obstetric and primary care bodies, and incorporates evidence‑based risk assessment criteria, tiered monitoring schedules, and clear referral thresholds. The guideline identified failures in current practice, noting that risk factors were not identified at booking and signs were not recognised or acted upon after 20 weeks gestation.

Abstract

Pre-eclampsia is a major cause of poor outcome in pregnancy: the category “hypertensive diseases of pregnancy” remains a leading cause of direct maternal deaths in the United Kingdom1; pre-eclamptic conditions represent one in three cases of severe obstetric morbidity2; hypertension and/or proteinuria is the leading single identifiable risk factor in pregnancy associated with stillbirth (one in five stillbirths in otherwise viable babies)3; and pre-eclampsia is strongly associated with fetal growth restriction, low birth weight, preterm delivery, respiratory distress syndrome, and admission to neonatal intensive care.4 In 46% of maternal deaths1 and 65% of fetal deaths5 due to pre-eclampsia reported through the Confidential Enquiries into Maternal Deaths and the Confidential Enquiry into Stillbirths and Deaths in Infancy, different management would reasonably have expected to alter the outcome. There was a failure to identify and act on known risk factors at booking and to recognise and respond to signs and symptoms from 20 weeks' gestation.6 No guidelines exist for the screening and early detection of pre-eclampsia in the community, and there is no uniformity in referral thresholds and assessment procedures. We developed the pre-eclampsia community guideline (PRECOG) under the auspices of the charity Action on Pre-eclampsia, following the National Institute for Clinical Excellence's recommendations for the development of guidelines.7 Our guideline is supported by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of General Practitioners, and the National Childbirth Trust. Box 1 lists the definitions used in the guideline; pre-eclampsia is defined as new hypertension and proteinuria (see bmj.com for definition of levels of evidence). The pre-eclampsia community guideline provides an evidence based risk assessment, with criteria for early referral for specialist input, a two tiered schedule for monitoring women in the community after …