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If used in pregnancy, these lower thresholds may identify women at increased risk of adverse outcomes, which would be particularly useful to risk-stratify nulliparous women. In this secondary analysis of the SCOPE cohort, we asked whether, among standard-risk nulliparous women, the ACC\/AHA BP categories could identify women at increased risk for adverse outcomes.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods and findings<\/jats:title>\n<jats:p>Included were pregnancies in the international SCOPE cohort with birth at \u226520 weeks\u2019 gestation, 2004 to 2008. Women were mostly of white ethnicity, in their 20s, and of normal-to-overweight body mass index (BMI). Excluded were pregnancies ending in fetal loss at &lt;20 weeks\u2019 gestation, and those terminated at any point in pregnancy. Women were categorized by highest BP during pregnancy, using ACC\/AHA criteria: normal (BP &lt;120\/80 mmHg), \u201cElevated BP\u201d (BP 120 to 129 mmHg\/&lt;80 mmHg), \u201cStage-1 hypertension\u201d (systolic BP [sBP] 130 to 139 mmHg or diastolic BP [dBP] 80 to 89 mmHg), and \u201cStage-2 hypertension\u201d that was non-severe (sBP 140 to 159 mmHg or dBP 90 to 109 mmHg) or severe (sBP \u2265160 mmHg or dBP \u2265110 mmHg). Primary outcomes were preterm birth (PTB), low birthweight, postpartum hemorrhage, and neonatal care admission. Adjusted relative risks (aRRs) and diagnostic test properties were calculated for each outcome, according to: each BP category (versus \u201cnormal\u201d), and using the lower limit of each BP category as a cut-off. RRs were adjusted for maternal age, BMI, smoking, ethnicity, and alcohol use. Of 5,628 women in SCOPE, 5,597 were included in this analysis. When compared with normotension, severe \u201cStage 2 hypertension\u201d was associated with PTB (24.0% versus 5.3%; aRR 4.88, 95% confidence interval, CI [3.46 to 6.88]), birthweight &lt;10th centile (24.4% versus 8.8%; aRR 2.70 [2.00 to 3.65]), and neonatal unit admission (32.9% versus 8.9%; aRR 3.40 [2.59 to 4.46]). When compared with normotension, non-severe \u201cStage 2 hypertension\u201d was associated with birthweight &lt;10th centile (16.1% versus 8.8%; aRR 1.82 [1.45 to 2.29]) and neonatal unit admission (15.4% versus 8.9%; aRR 1.65 [1.31 to 2.07]), but no association with adverse outcomes was seen with BP categories below \u201cStage 2 hypertension.\u201d When each BP category was assessed as a threshold for diagnosis of abnormal BP (compared with BP values below), only severe \u201cStage 2 hypertension\u201d had a useful (good) likelihood ratio (LR) of 5.09 (95% CI [3.84 to 6.75]) for PTB. No BP threshold could rule-out adverse outcomes (i.e., had a negative LR &lt;0.2). Limitations of our analysis include lack of ethnic diversity and use of values from clinical notes for BP within 2 weeks before birth. This study was limited by: its retrospective nature, not all women having BP recorded at all visits, and the lack of detail about some outcomes.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>In this study, we observed that 2017 ACC\/AHA BP categories demonstrated a similar pattern of association and diagnostic test properties in nulliparous women, as seen in the general obstetric population. BP thresholds below the currently used \u201cStage 2 hypertension\u201d were not associated with PTB, low birthweight, postpartum hemorrhage, or neonatal unit admission. This study does not support implementation of lower BP values as abnormal in nulliparous pregnant women.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pmed.1004471","type":"journal-article","created":{"date-parts":[[2025,1,22]],"date-time":"2025-01-22T18:41:15Z","timestamp":1737571275000},"page":"e1004471","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Diagnostic properties of differing BP thresholds for adverse pregnancy outcomes in standard-risk nulliparous women: A secondary analysis of SCOPE cohort 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N.","family":"Bone","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6127-8282","authenticated-orcid":true,"given":"Milly","family":"Wilson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9783-5893","authenticated-orcid":true,"given":"Nuhaat","family":"Syeda","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lucilla","family":"Poston","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4136-3070","authenticated-orcid":true,"given":"Peter","family":"von Dadelszen","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1355-610X","authenticated-orcid":true,"given":"Laura 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