Recent changes in diagnosis, management of preeclampsia by ACOG

Recently ACOG has made the following observations as regards diagnosis, management of preeclampsia

• First and foremost observation made by ACOG is that proteinuria should no longer be considered the signature criterion in diagnosing preeclampsia. How things have changed over the years. When we were students preeclampsia was considered a TRIAD of three signs: Hypertension, Edema and Proteinuria. Later Edena as a criteria for diagnosis was dropped as it came to be realised that edema is an incidental finding in preeclamsia and has no bearing on severity or prognosis. And now in 2014, ACOG says: “Proteinuria, in addition to being downgraded as the signature diagnostic finding in preeclampsia, should no longer be considered as useful in classifying preeclampsia as severe or in deciding whether to induce, the guidelines say, because the amount of protein in the urine has not been shown to predict either maternal or fetal outcomes.”
• ACOG says that equal weight should be given to reduced platelet counts, renal insufficiency, severe headache, heart-lung compromise, and impaired liver function. Any one of these concurrent with new-onset hypertension at 20 weeks of pregnancy or beyond is enough to establish preeclampsia, even in the absence of proteinuria. I feel vindicated about this because I have already said in II edition of my textbook, Modern Obstetrics, that significant hypertension with any organ damage such as kidneys, liver, lung, heart, brain etc. should be called preeclampsia. As I have said in my book “nonproteinuric preeclampsia is now a diagnostic entity”
• Another important change is that preeclamsia is no longer considered as Mild and Severe. Now ACOG guidelines distinguish extensively between preeclampsia with and without severe features, but discourage the use of the phrase "mild preeclampsia," considering it misleading. "Preeclampsia in any form should never be minimized as ‘mild.’
• Fetal growth restriction (FGR), once considered a major criterion to make the diagnosis of severe preeclampsia, is now to be used not for diagnosis of preeclampsia, but for indicated delivery in a patient with preeclampsia who also has an extremely small fetus (< 5th centile) that is associated with abnormal blood flow findings in the umbilical cord connecting the fetus to the placenta.
• The guidelines emphasize that preeclampsia can appear for the first time following delivery, or worsen rather than improve during in the postnatal period.
• As regards prevention, ACOG has this to say: The use of vitamins C and E is not advised in preventing preeclampsia. Low-dose aspirin, however, is recommended starting late in the first trimester for patients who experience preterm severe preeclampsia.
• Delivery at 37 weeks is advised for women with preeclampsia without severe features.