. 2019 May 17;6:55. doi: 10.3389/fcvm.2019.00055

Table 1.

Summary of international guidelines with the level of evidence for individual recommendations.

Guideline	Year	Specialist referral (graded level of evidence)	Recommendations for Investigations and monitoring frequency and follow up time (graded level of evidence)	Risk factor modification and other preventative actions (graded level of evidence)	Quality of evidence (based on GRADE principles)
National Institute for health and Care Excellence (NICE) clinical guideline 107 (5).	2011	Those who have no proteinuria and are normotensive at the postnatal review require no further renal follow-up (2^b).	Thrombophilia screening is not indicated (2^a).	Women should be told, along with their primary care physicians, that these conditions are associated with an increased risk of developing CVD (3a−)^*1. Women should maintain a BMI between 18.5 to 24.9 kg/m2, in line with NICE clinical guideline 43 (2^b).	Moderate.
National Collaborating Center for Women's and Children's Health (UK). Hypertension in Pregnancy: The Management of Hypertensive Disorders During Pregnancy (6).	2010	Not specified.	Further follow-up is necessary but unsatisfactory evidence to support recommendations on frequency of follow up or BP monitoring (3^a).	Inform women and their primary care clinicians of the possibilities of developing high BP and its complication in the future (3a).	Low.
ESC/ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) (7).	2018	Not specified.	Recommends annual visits to a primary care physician for BP checks and to check other metabolic factors (2^a). Recommends long-term specialist follow-up.	Previous hypertension in pregnancy or pre-eclampsia should be part of a clinical history. Lifestyle modifications are indicated to reduce future cardiovascular risk (2^a).	low.
The European Society of Cardiology guideline on the management of cardiovascular diseases during pregnancy (8).	2011	Not specified.	Regular BP monitoring and control of metabolic risk factors (3a-)^*4.	Lifestyle changes to minimize difficulties in future pregnancies and reduce the possibilities of developing cardiovascular disease in the future (2a−)^*5.	Low.
Institute of Obstetricians and Gynecologists Ireland Clinical Practice guideline No. 3 (9).	2016	All patients with severe pre-eclampsia to be offered hospital follow-up within 12 weeks of delivery (5).	Blood pressure and proteinuria assessment should be carried out and specialist referral made if there is ongoing hypertension, need for antihypertensives or significant proteinuria (5).	Discuss potential risk factors such as obesity and aspirin therapy (5).	Very low.
Institute of Obstetricians and Gynecologists Ireland Clinical Practice guideline No. 37. (10).	2016	Further care after 6 weeks for any ongoing pregnancy related changes, in particular chronic high blood Pressure, ongoing need for antihypertensives, high BMI or incidence of pre-term pre-eclampsia (5). Provide expert review if still on antihypertensive medicines by 6–8 weeks (5).	Yearly BP and standard cardiovascular risk assessment including serum lipids and blood glucose (5). Women with persistent hypertension should undergo treatment and investigation in line with standard protocols (5).	Psychotherapy for women with history of had hypertensive disorders in pregnancy to promote their well-being and lifestyle advice including avoiding smoking, maintaining a healthy body mass, engaging in regular exercise and maintaining a balanced diet (5).	Very low.
Hypertension and Pregnancy: expert consensus statement from the French Society of Hypertension, an affiliate of the French Society of Cardiology (11).	2017	Women should be reviewed by a consultant to ensure that CVD and renal disease risk factors are identified and controlled (2^a). Assessment and management of all CVD and renal risk factors should be offered to all women via a multidisciplinary care-plan (2^a).	Women with a known past medical history of high BP during pregnancy should undergo BP (3^a), renal function and urinalysis monitoring (2^a).	Highlights the importance of a multi-disciplinary approach in monitoring and ensuring a healthy life style and modulation of CVD risk factors (5). Women should be provided with information concerning the possibilities of developing high BP and its complication in the future (3^a).	Low.
Promoting Risk Identification and Reduction of Cardiovascular Disease in Women Through Collaboration With Obstetricians and Gynecologists: A Presidential Advisory From the American Heart Association and the American College of Obstetricians and Gynecologists (12).	2018	Recommendations are given for all women and not specific to those with HDP.	Blood pressure should be checked yearly for those ≥40 years or those with increased risk for high blood pressure (including HDP) (2^a).	Recommendations are given for all women and not specific to those with HDP.	Low.
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines (13).	2017	Not specified.	No evidence that blood pressure thresholds, blood pressure targets, treatment choices or antihypertensive combinations should differ in women compared to men (1^a).	Not specified.	Moderate.
The American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy (14).	2013	Not specified.	Yearly BP and risk factor monitoring (such as lipids, fasting blood glucose and BMI) suggested for women with medical history of recurrent pre-eclampsia and pre-term pregnancy (< 37 weeks) (5).	Women should maintain a healthy lifestyle in terms of maintaining an optimum body weight, consuming a diet high in fiber, fruit and vegetables and low in fat and avoid tobacco (5). Evaluate the future risk of cardiovascular disease (2^a-)^*6.	Very low.
Effectiveness Based Guidelines for The Prevention of CVD in Women: A Guideline From the American Heart Association (15).	2011	Women should be referred post-partum to a primary care physician or cardiologist to aid future care plan and manage risk factors (3^a-)^*1.	Not specified	Emphasizes the need for female-based guidelines (5). Hypertensive disorders of pregnancy should be part of a detailed cardiovascular history (3^a-)^*1.	Very low.
The Association of Ontario Midwives clinical practice guideline 15 (16).	2012	Thorough examination post-partum period within 4 weeks and further post-partum visits or clinician consultation if clinical manifestations of HDP beyond 4 weeks (3^b). Communication between clinicians and community healthcare providers on future blood pressure care (3^a).	Not specified	Inform women of their risk of developing pre-eclampsia in future pregnancies and Information about hypertensive disorders of pregnancy should be passed onto primary care physicians (3^a-)^*3. Dietary and lifestyle changes—exercise activity, reducing fat and salt intake to reduce high BP at the later life recommended for pregnant women (5).	Very low.
The Guidelines for the Prevention of Stroke in Women, a Statement for Healthcare Professionals from the American Heart Association and American Stroke Association (17).	2014	Review all women from 6 TO 12 months post-partum and menopausal women and record history of preeclampsia/eclampsia as a risk factor (3a−)^*7.	Lipids levels should be tested (1c−^*8).	Evaluate and treat for cardiovascular risk factors such as high BP (3a−^7), overweight women, smoking and elevated lipids levels (1c-)^8.	Moderate.
Society of Obstetricians and Gynecologists of Canada Clinical Practice Guideline 307 (18)	2014	Referral to internal or renal medicine should be considered in women with refractory post-partum hypertension or indicators of renal disease beyond 3–6 months (3^a).	Women with underlying hypertension or persistent postpartum hypertension should undergo urinalysis, renal function and electrolytes, fasting glucose, fasting lipids and 12-lead electrocardiography at least 6 weeks post-partum (3a). Women who are normotensive at discharge may benefit from assessment of cardiovascular risk factors and women with a history of severe pre-eclampsia should be screened for underlying hypertension or renal disease (2^a)	All women who have had a hypertensive disorder of pregnancy should maintain a healthy diet, lifestyle and BMI (2^a)	Low.
The SOMANZ Guideline for the Management of Hypertensive Disorders of Pregnancy (19)	2014	Not specified	Women should have an annual BP check and 5 yearly assessment of CVD risk factors including serum glucose and lipid profiles (5)	Women would benefit from a healthy lifestyle that included a healthy weight, not smoking, exercise and a healthy diet (3a−)^*2.	Very low.
The Queensland Maternity and Neonatal Clinical Guidelines Program Guideline No. MN10.13.V4-R15 (20)	2010	Not specified	Women should be screened for pre-existing hypertension and underlying renal disease (2a) Cardiovascular risk factors (e.g., BP, lipid profile and serum glucose) should be assessed regularly with patient-centered follow up time (3^a).	Post-natal counseling should include consultation on risk factors and preventative therapies such as calcium supplementation and low dose aspirin (3^a). Women should maintain a healthy lifestyle in terms of diet, exercise and avoidance of tobacco (3^a−^*9).	Low.

Minus plus

indicated were there are issues with scoring the level of evidence as listed below such as heterogeneity/or has stated below.

^*1

Heterogeneity I² = 62.6% for increased risk of future hypertension with evidence of small study projecting larger effects size. Low heterogeneity for Stroke = I² = 0% for Stroke (no evidence of small study bias P = 0.82) and IHD and I² = 27.1% (no evidence of small study bias P = 0.59). More recent paper in 2008 uses Systematic review on cohort with two additional cohorts and case control studies and scores heterogeneity I² scores ranging from 35.7 to 66.3%. Evidence also measures the severity of pre-eclampsia and CVD Risk using meta regression.

^*2

Similar papers on meta-analysis/systematic review used on lifestyle factors as annotated 1.

^*3

Same papers used as evidenced for annotated 1.

^*4

One of the evidence used focuses on maternal placental syndrome/poor fetal growth and no measurement on weight and HBP to reduce bias on obese women.

^*5

Systematic reviews examined for both randomized and large prospective cohort studies.

^*6

Clear evidence with pre-eclampsia and future CV, however the significance and applicable stages are not established.

^*7

Case control Dutch study and Cohort/systematic reviews similar papers as annotated 1.

^*8

Lipids in obese women doesn't have a clear focus on pregnant women.

^*9

Referenced Somanz guideline as per annotated 2, same evidence applies as annotated 1.

Level of evidence 1:

1a,Systematic reviews (with homogeneity) of randomized controlled trials;1b,Individual randomized controlled trials (with narrow confidence interval); 1c, All or none randomized controlled trials;2a, Systematic reviews (with homogeneity) of cohort studies; 2b, Individual cohort study or low quality randomized controlled trials (e.g., < 80% follow-up);2c, “Outcomes” Research; ecological studies; 3a, Systematic review (with homogeneity) of case-control studies; 3b, Individual case-control study; 4, Case series (and poor-quality cohort and case-control studies); 5, Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles;” (21).