Hypertension in Pregnancy NICE Guidelines with additional diagnostic test for the PARROT trial Mild hypertension BP up to 149/99 mmHg Do not admit to hospital. Do not treat hypertension. Measure BP no more than x1/wk Test for proteinuria at each visit Carry out routine antenatal blood tests. If presenting before 32/40, or at high risk of pre-eclampsia, test for proteinuria and measure BP x2/ wk. Moderate hypertension BP 150/100–159/109 mmHg Do not admit to hospital. Treat hypertension to keep BP <150/ 80–100 mmHg. Measure BP at least x2/ wk. Test for proteinuria at each visit Test kidney function, electrolytes, FBC, transaminases, bilirubin. No further blood tests if no subsequent proteinuria. Arrange fetal USS Severe hypertension BP ≥ 160/110 mmHg Admit to hospital until BP ≤159/109 mmHg and treat hypertension to keep BP < 150/80–100 mmHg. Measure BP at least x4/ day Test for proteinuria daily Test kidney function, electrolytes, FBC, transaminases, bilirubin at presentation & then weekly. Arrange fetal USS Continue care as in guidelines pathway; integrate additional information from PlGF test as shown below PlGF >100 NORMAL PlGF 12-100 LOW PlGF <12 VERY LOW CONTINUE WITH USUAL MANAGEMENT CONSIDER INCREASED SURVEILLANCE ASSESS AS PRE-ECLAMPSIA This protocol is an example used in the NICE medical technology guidance adoption support resource for PlGF- based testing to help diagnose suspected pre-eclampsia. It was not produced for or commissioned by NICE Algorithm version 3.0 Jan 2016 ©2016 King’s College London

PlGF >100 pg/ml NORMAL PlGF 12-100 pg/ml LOW PlGF <12 pg/ml VERY LOW Normal test result: suggestive that no placental dysfunction. Unlikely to progress to delivery within 14 days. What does it mean?: 98% of women who are in this green range will not need delivery for pre-eclampsia within 14 days. Median time to delivery: < 35 weeks: 62 days 35-37 weeks: 16 days Plan: continue with usual management. Abnormal test result – low: suggestive of placental dysfunction. Increased risk for preterm delivery. What does it mean? A PlGF test result <100 pg/ml will correctly identify 95-96% of women with pre-eclampsia who need delivery within 14 days. Median time to delivery: < 35 weeks: 23 days 35-37 weeks: 9 days Plan: consider increased surveillance (e.g. moving one step up on the NICE chart above), with regular monitoring and fetal ultrasound if indicated. Highly abnormal test result – very low: suggestive of severe placental dysfunction (i.e. placental ‘growth’ is very low). What does it mean? The red range highlights those at highest risk of preterm delivery, including delivery of an SGA infant. For women presenting before 35 weeks with PlGF <12 pg/ml, 94% will be delivered preterm. Median time to delivery: < 35 weeks: 9 days 35-37 weeks: 4 days Plan: consider as ‘pre-eclampsia’ (regardless of proteinuria) with admission for assessment, increased surveillance and fetal ultrasound if indicated. Chappell et al Circulation 2013 LOW OR VERY LOW PLGF RESULT IS NOT AN INDICATION FOR DELIVERY IN ITSELF Algorithm version 3.0 Jan 2016 ©2016 King’s College London