Pregnancy · Risk

Preeclampsia Diagnostic Criteria

Determine whether ACOG 2020 / ISSHP 2018 criteria for preeclampsia are met, including the seven severe features that change management completely. Educational tool to inform conversations with your obstetric team.

Last reviewed 25 May 2026

Preeclampsia diagnostic criteria — ACOG 2020

Do I meet criteria for preeclampsia?

wk

Proteinuria

Severe features (any ONE = preeclampsia with severe features)

Enter gestational age and check the criteria.
Educational tool only — not medical advice. The ACOG 2020 criteria removed proteinuria as a mandatory diagnostic feature — end-organ damage (thrombocytopenia, liver/renal involvement, neurological symptoms) without proteinuria still establishes the diagnosis. If you have hypertension in pregnancy with ANY symptom on this list, contact your obstetric team or maternity assessment unit TODAY.
What does this mean?
Pre-eclampsia is a placental disease that affects 2–8 % of pregnancies and is a top global cause of maternal and perinatal mortality. The ACOG 2020 criteria removed proteinuria as mandatory: new hypertension after 20 wk + any end-organ damage (low platelets, elevated transaminases, renal dysfunction, pulmonary oedema, new headache/visual disturbance) is enough to diagnose. Severe features (BP ≥ 160/110, PLT < 100, Cr doubled, AST ≥ 2× ULN, pulmonary oedema, persistent headache or RUQ pain) trigger delivery if ≥ 34 wk, magnesium for seizure prophylaxis, and labetalol/nifedipine for severe BP. Definitive treatment is delivery — pre-eclampsia resolves over days– weeks postpartum, though up to a quarter develop NEW or worsening features after birth. Lifelong relevance: women with PE history have ~2× cardiovascular disease risk and need long-term BP / metabolic follow-up (NICE NG133, ESC 2024).

Introduction

Preeclampsia is a pregnancy-specific hypertensive disorder affecting 2-8 % of pregnancies. The 2020 ACOG Practice Bulletin 222 (reaffirmed 2024) refined the diagnostic criteria — most importantly establishing that proteinuria is NO LONGER MANDATORY: end-organ damage in the right clinical context is enough.

Background — the diagnostic shift

Until 2013, preeclampsia required new-onset hypertension AND proteinuria. About 14 % of women with preeclampsia present without significant proteinuria but with thrombocytopenia, liver / renal involvement, pulmonary oedema, or neurological symptoms. ACOG 2013 acknowledged this and revised the criteria; ACOG 2020 further refined alignment with the International Society for the Study of Hypertension in Pregnancy (ISSHP) 2018 statement.

How to read this calculator

Enter gestational age, check whether new-onset hypertension is present, indicate proteinuria status, and tick any severe features. The output gives you one of four conclusions: criteria not met, gestational hypertension (BP but no other criteria), preeclampsia without severe features, or preeclampsia WITH severe features. The last is an emergency.

The full ACOG 2020 criteria

Required

New-onset hypertension at ≥ 20 weeks — SBP ≥ 140 mmHg OR DBP ≥ 90 mmHg, on at least 2 measurements at least 4 hours apart. (Or SBP ≥ 160 / DBP ≥ 110 confirmed within minutes — immediate action.)

PLUS either

Proteinuria: 24-hour urine ≥ 300 mg, protein:creatinine ratio ≥ 0.3, or dipstick ≥ 2+ in absence of quantitative measure.

OR any ONE end-organ feature

  • Platelets < 100,000 / µL
  • Creatinine > 1.1 mg/dL or doubling of baseline (no other cause)
  • Liver transaminases ≥ 2× upper limit of normal
  • Pulmonary oedema
  • New-onset persistent headache or visual disturbance

Severe features (any ONE = preeclampsia with severe features)

  • SBP ≥ 160 mmHg or DBP ≥ 110 mmHg (confirmed within minutes).
  • Platelets < 100,000 / µL.
  • Creatinine > 1.1 mg/dL or doubling (without other cause).
  • Liver transaminases ≥ 2× ULN.
  • Pulmonary oedema.
  • Persistent severe headache / visual disturbance.
  • Severe persistent right-upper-quadrant or epigastric pain.

Why severe features change everything

Severe-features preeclampsia carries substantially higher risk of eclampsia (seizures), HELLP syndrome, stroke, placental abruption, renal failure, and stillbirth. Management changes from outpatient monitoring to immediate hospitalisation with:

  • BP control with IV labetalol, hydralazine, or oral nifedipine — target SBP < 160 and DBP < 110.
  • Magnesium sulphate 4-6 g IV loading, then 1-2 g/hour for seizure prophylaxis (24 hours post-delivery, or 24 hours after last seizure).
  • Frequent labs (FBC, LFTs, U&E, uric acid every 6-12h).
  • Continuous fetal monitoring.
  • Plan for delivery typically within 24-48 hours regardless of gestational age (consider expectant management 24-34 weeks in tertiary centres with stable mother and reassuring fetus, balancing maternal risk vs prematurity).

Management without severe features

Outpatient or inpatient monitoring depending on access and clinical concern:

  • BP monitoring 2-3× weekly.
  • Weekly labs (FBC, LFTs, U&E, uric acid).
  • Twice-weekly fetal surveillance (NST + AFI / BPP).
  • Delivery at 37 weeks (ACOG / NICE recommendation — earlier than spontaneous timing because risk of severe-feature progression rises with each week).

HELLP syndrome — the severe spectrum end

About 10-20 % of severe preeclampsia develops HELLP syndrome — Haemolysis, Elevated Liver enzymes, Low Platelets. Sibai “Tennessee” criteria: LDH > 600 or bilirubin > 1.2 (haemolysis), AST ≥ 70, PLT < 100,000. Higher maternal mortality than preeclampsia alone. See the HELLP classifier.

Postpartum considerations

  • Preeclampsia can present or worsen 1-7 days postpartum (postpartum preeclampsia / eclampsia). Continue BP monitoring 1-2 weeks post-discharge.
  • BP usually normalises within 6-12 weeks. 10-30 % persist hypertensive and need continued treatment.
  • Long-term: 2-fold increase in cardiovascular disease risk over the next 15-20 years (Bellamy 2007 BMJ). Annual BP, lipid screening, and lifestyle modification from age 30 onward.

Limitations

  • This is an educational tool that reflects ACOG / ISSHP criteria. It cannot replace clinical assessment with vital signs, lab results, and obstetric judgment.
  • Some women have preeclampsia symptoms with borderline values; those need clinician interpretation in context.
  • Chronic hypertension that worsens in pregnancy is "superimposed preeclampsia" — different category; this calculator covers de-novo preeclampsia.
  • If you have any of the severe features listed, do not wait for this calculator to confirm a diagnosis — ring your maternity unit or attend A&E now.

Sources

  • ACOG. Practice Bulletin 222: Gestational Hypertension and Preeclampsia. 2020 (reaffirmed 2024).
  • Brown MA, Magee LA, Kenny LC, et al. Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice. Hypertension 2018;72:24-43.
  • NICE. Hypertension in pregnancy (NG133). 2019.
  • Bellamy L, et al. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ 2007;335:974.
  • Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol 2004;103:981-91.

Frequently asked questions

What is preeclampsia?
A pregnancy-specific hypertensive disorder, typically arising after 20 weeks, characterised by new-onset high blood pressure plus signs of end-organ dysfunction (proteinuria, thrombocytopenia, renal/liver involvement, neurological or pulmonary symptoms). It affects 2-8 % of pregnancies and is a leading cause of maternal and fetal morbidity. Untreated severe preeclampsia can progress to eclampsia (seizures), HELLP syndrome, stroke, placental abruption, and stillbirth.
How did the diagnostic criteria change in 2013/2020?
ACOG 2013 removed proteinuria as MANDATORY for diagnosis — recognising that ~14 % of preeclampsia presents without significant proteinuria but with other end-organ involvement. ACOG 2020 (PB 222, reaffirmed 2024) refined the severe-feature list and aligned with ISSHP 2018 international criteria. The current standard: new-onset hypertension at ≥ 20 weeks PLUS EITHER proteinuria OR any one of thrombocytopenia / renal / liver / pulmonary / neurological feature.
What are severe features and why do they matter?
Any ONE of: SBP ≥ 160 or DBP ≥ 110 confirmed, platelets < 100,000, creatinine > 1.1, transaminases ≥ 2× ULN, pulmonary oedema, persistent severe headache or visual disturbance, severe persistent RUQ / epigastric pain. The presence of severe features changes management completely — usually means immediate admission, magnesium sulphate for seizure prophylaxis, BP control with IV labetalol/hydralazine, and plan for delivery typically within 24-48 hours regardless of gestation (with shared decision about expectant management between 24-34 weeks in tertiary centres).
Can preeclampsia be cured?
Only by delivery of the placenta. There's no medication that 'cures' preeclampsia — antihypertensives control BP, magnesium sulphate prevents seizures, but the underlying placental pathology resolves only when the placenta is delivered. This is why the threshold for delivery is lower than people expect: at term (37+ weeks) with preeclampsia, delivery is recommended; at preterm with severe features, delivery within 24-48 hours often outweighs continued pregnancy.
What's gestational hypertension vs preeclampsia?
Gestational hypertension = new-onset BP ≥ 140/90 at ≥ 20 weeks WITHOUT proteinuria or end-organ features. About 25 % of women with gestational hypertension go on to develop preeclampsia within weeks. So gestational hypertension is a 'watch carefully' diagnosis — frequent BP / urine / lab monitoring, watch for severe features, often delivered at 37-38 weeks.
What happens after preeclampsia?
BP usually normalises within 6-12 weeks postpartum. About 10-30 % of women have persistent hypertension postpartum requiring continued antihypertensive treatment. Women with preeclampsia have significantly elevated lifetime cardiovascular disease risk (2-fold increase in heart attack, 2-fold in stroke, 1.5-fold in CV mortality — Bellamy 2007 BMJ meta-analysis). Annual BP screening, lipid surveillance, lifestyle modification from age 30 onwards are recommended (AHA Women's Heart Risk Calculator includes preeclampsia history).
Will I get preeclampsia again?
Recurrence rate is roughly 15-20 % overall — higher (40-60 %) if first preeclampsia was severe or early-onset (< 34 weeks). Aspirin prophylaxis (75-150 mg from 12-16 weeks) is recommended in subsequent pregnancies to reduce risk by ~30-60 %. See the Aspirin for Preeclampsia Prevention calculator. Other interventions: optimising weight, BP, and diabetes control before conception; specialist preconception consultation if you had severe early-onset PE.

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