Professional Documents
Culture Documents
12173
2015;17:918
Review
MBBS BSc,
Clinical Research Fellow, Womens Health Academic Centre, Kings College London, 10th floor, North Wing, St Thomas Hospital,
London SE1 7EH, UK
b
Academic Clinical Fellow, Womens Health Academic Centre, Kings College London, 10th floor, North Wing, St Thomas Hospital,
London SE1 7EH, UK
c
Clinical Senior Lecturer, Womens Health Academic Centre, Kings College London, 10th floor, North Wing, St Thomas Hospital,
London SE1 7EH, UK
d
Professor of Obstetrics, Womens Health Academic Centre, Kings College London, 10th floor, North Wing, St Thomas Hospital,
London SE1 7EH, UK
*Correspondence: Andrew H Shennan. Email: andrew.shennan@kcl.ac.uk
Key content
Learning objectives
Ethical issues
hypertension / pre-eclampsia
Please cite this paper as: Nathan HL, Duhig K, Hezelgrave NL, Chappell LC, Shennan AH. Blood pressure measurement in pregnancy. The Obstetrician &
Gynaecologist 2015;17:918.
Introduction
Hypertensive disorders in pregnancy, which include preeclampsia,
gestational
hypertension
and
chronic
hypertension, complicate 28% of pregnancies and confer
risk to the health of mother and fetus.1 Pre-eclampsia is one
of the three leading causes of maternal death in the UK and
can result in substantial maternal morbidity, including
intracranial haemorrhage, HELLP (haemolysis, elevated
liver enzymes and low platelet count) syndrome and
disseminated intravascular coagulation.2 In 2010 an
estimated 287 000 maternal deaths occurred globally, 99%
of which occurred in low- and middle-income countries
(LMICs). Approximately 14% of these deaths were thought
to be related to hypertensive disorders in pregnancy,3
91
Pregnancy BP measurement
Auscultatory technique
The National Institute for Health and Care Excellence
(NICE)5 Antenatal Care guidance recommends BP
measurement at every antenatal visit and outlines the steps
involved in BP measurement using the auscultatory
technique. This includes use of the correct-sized cuff, initial
inflation of the cuff 2030 mmHg above the palpable systolic
BP, deflation at a rate of 2 mmHg per second, recording BP
to the nearest 2 mmHg and use of Korotkoff phase V to
indicate diastolic BP. For example, deflating the cuff too fast
will result in underestimation of the systolic BP and
overestimation of the diastolic BP. Despite these clear
recommendations, in clinical practice BP measurement is
often not performed correctly, leading to inaccurate readings,
92
Korotkoff IV versus V
Up until the late 1990s there was debate as to whether
Korotkoff phase IV (muffling of sound, K4) or Korotkoff
phase V (disappearance of sound, K5) should be used to
classify diastolic BP in pregnancy. It was argued that K4 was
more appropriate considering the unique haemodynamics of
pregnancy and because it was thought that K5 could often
extend to or near zero (since shown to be very rare).6 A
randomised controlled trial published in The Lancet in 1998,7
comparing outcome in hypertensive disorders in pregnancy
managed according to either K4 or K5, demonstrated that an
episode of severe hypertension was more likely in women in
the K4 group, mainly because diastolic hypertension was
more likely to be recorded. However, the frequency of severe
systolic hypertension, simultaneous systolic and diastolic
hypertension, and maternal and fetal adverse clinical
outcome did not differ between the two groups.
Considering these findings and that K5 is better reflective
of intra-arterial pressure and is far more reproducible,8 the
use of K5 to classify diastolic BP was recommended and has
since been included in the NICE5 Antenatal Care guidelines.
Nathan et al.
Aneroid devices
Aneroid devices remove the need to use mercury in clinical
settings, but the inherent errors associated with
sphygmomanometry and the use of Korotkoff sounds with
auscultation remain. Furthermore, aneroid devices require more
frequent maintenance and calibration than mercury
sphygmomanometers. A survey of BP devices used by UK
general practitioners showed that only 50% of devices had been
serviced within 1 year and 24% had never been serviced,13
increasing the chance of error. Likewise, an observational study of
devices used in UK general practices demonstrated that 53% of
aneroid devices were reading in error by more than 3 mmHg,
far more than the mercury and automated devices.14 Although a
seemingly small difference from the true reading, a systematic
underestimation of BP by 3 mmHg would lead to one-quarter of
patients with hypertension being falsely classified as
normotensive.15 As long as aneroid devices are regularly
maintained and calibrated, their accuracy can be assumed to be
similar to mercury devices, as shown in an observational study
evaluating the accuracy of aneroid devices used clinically,
compared with a calibrated mercury sphygmomanometer.16
http://www.dableducational.org/sphygmomanometers/
devices_1_clinical.html#ClinTable
93
Pregnancy BP measurement
94
Nathan et al.
Ambulatory/self-monitoring
White-coat hypertension describes a group of individuals
who are normotensive in their home environment, but who
present with an elevated BP to a healthcare provider. Whitecoat hypertension has been shown to be an independent
predictor of cardiovascular risk.34 A prospective
observational study of women with chronic and white-coat
hypertension in pregnancy demonstrated that 40% of those
with white-coat hypertension developed hypertensive
disorders in pregnancy and 8% developed pre-eclampsia,
significantly fewer than the 22% with chronic hypertension
who developed pre-eclampsia (P<0.008).35 Diurnal variation
in BP is a well-documented phenomenon; in pregnancies
complicated by hypertension or pre-eclampsia this change in
circadian rhythm may be altered,36 and is seen to be reversed
in those with severe hypertensive disorders in pregnancy
towards the end of pregnancy.37
Automated, ambulatory BP devices have been used to
assess women at home, to overcome the low sensitivity and
specificity of clinic BP measurement. In the home setting,
ambulatory readings enable differentiation of true white-coat
hypertension from hypertensive disorders in pregnancy, and
assess patterns of BP variation throughout the day. It has long
been recognised that automated 24-hour BP readings
improve the identification of women who are at risk of
poor obstetric outcome.38 More recent evidence has shown
that as early as the first trimester, statistically significant
differences in 24-hour BP are seen in women with subsequent
hypertensive versus normotensive pregnancies.39 Ambulatory
BP monitoring is well tolerated with high rates of
compliance,40 and with established reference ranges41 in
pregnancy, the use of ambulatory monitoring should be
encouraged and expanded in the obstetric population. The
use of self-monitoring is simpler, cheaper, is more acceptable
to women and provides many of the advantages of
ambulatory monitoring, while also improving surveillance
and reducing scheduled visits.42
95
Pregnancy BP measurement
to
96
Conclusion
Hypertensive disorders in pregnancy, obstetric haemorrhage,
sepsis and unsafe termination of pregnancy contribute to
more than half of all maternal deaths globally. The diagnosis
and management of each of these conditions is guided, in
part, by the measurement of BP. It is therefore important
that clinicians caring for women with these conditions are
able to measure BP correctly and to appreciate the
importance of accurate measurement, and the significance
of the measurement which is often very different from
non-pregnant patients. Healthcare professionals should be
aware of the advantages and disadvantages of the various BP
devices available and feel confident to raise concern
regarding devices inaccurate for use in pregnancy or poor
technique observed.
In the absence of high-grade evidence, the national
guidelines for hypertensive disorders in pregnancy on
intervention according to BP thresholds are largely based
on expert opinion, particularly regarding mild-to-moderate
hypertension. For severe hypertension, there are a small
number of studies suggesting that severe systolic
hypertension is a better indicator than diastolic
hypertension of the risk of adverse cerebrovascular events.
Further well-designed clinical studies and trials are required
to evaluate the optimal threshold for intervention in women
with different types of hypertension in pregnancy, with
assessment of the efficacy of varying antihypertensive drug
classes. Likewise, the evidence regarding the use of vital signs
in the diagnosis and management of maternal shock is
limited. The impact of recognition of haemodynamic
compromise on mortality and significant morbidity was
highlighted in the 20062008 Confidential Enquiries report.4
Research should now focus on determining the optimal vital
sign predictor(s) and thresholds of this predictor to guide
assessment in obstetric shock.
Nathan et al.
Contribution to authorship
Substantial contributions to conception and design, or
acquisition of data, or analysis and interpretation of data
(HLN, KD, LCC, AHS). Drafting the article or revising it
critically for important intellectual content (HLN, KD, NLH,
LCC, AHS). Final approval of the version to be published
(HLN, KD, NLH, LCC, AHS).
Disclosure of interests
No conflict of interest is declared. No financial relationships
with any organisation that might have interest in the submitted
work in the previous three years are declared. No other
relationships or activities that could appear to have influenced
the submitted work are declared. All authors had full access to
all of the data in the study and can take full responsibility for
the integrity of the data and the accuracy of data analysis.
Kings College London is the guarantor for the study.
References
1 Duley L. The global impact of pre-eclampsia and eclampsia. Semin Perinatol
2009;33:1307.
2 Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia.
Lancet 2010;376:63144.
Moller AB, Daniels J, et al. Global
3 Say L, Chou D, Gemmill A, Tuncalp O,
causes of maternal death: a WHO systematic analysis. The Lancet Global
Health 2014;2:e32333.
4 Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D,
et al. Saving Mothers Lives: Reviewing maternal deaths to make
motherhood safer: 20062008. The Eighth Report of the Condential
Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118
(Suppl 1):1203.
5 National Institute for Health and Care Excellence. Antenatal Care. NICE
Clinical Guideline 62. London: NICE; 2008.
6 Higgins JR, de Swiet M. Blood-pressure measurement and classication in
pregnancy. Lancet 2001;357:1315.
7 Brown MA, Buddle ML, Farrell T, Davis G, Jones M. Randomised trial of
management of hypertensive pregnancies by Korotkoff phase IV or phase
V. Lancet 1998;352:77781.
8 Shennan A, Gupta M, Halligan A, Taylor DJ, de Swiet M. Lack of
reproducibility in pregnancy of Korotkoff phase IV as measured by mercury
sphygmomanometry. Lancet 1996;347:13942.
9 de Greeff A, Lorde I, Wilton A, Seed P, Coleman AJ, Shennan AH.
Calibration accuracy of hospital-based non-invasive blood pressure
measuring devices. J Hum Hypertens 2010;24:5863.
10 Mion D, Pierin AM. How accurate are sphygmomanometers? J Hum
Hypertens 1998;12:2458.
11 Perry IJ, Wilkinson LS, Shinton RA, Beevers DG. Conicting views on the
measurement of blood pressure in pregnancy. Br J Obstet Gynaecol
1991;98:2413.
12 Wen SW, Kramer MS, Hoey J, Hanley JA, Usher RH. Terminal digit
preference, random error, and bias in routine clinical measurement of blood
pressure. J Clin Epidemiol 1993;46:118793.
13 Hussain A, Cox JG. An audit of the use of sphygmomanometers. Br J Clin
Pract 1996;50:1367.
14 Coleman AJ, Steel SD, Ashworth M, Vowler SL, Shennan A. Accuracy of the
pressure scale of sphygmomanometers in clinical use within primary care.
Blood Press Monit 2005;10:1818.
15 Turner MJ, Baker AB, Kam PC. Effects of systematic errors in blood pressure
measurements on the diagnosis of hypertension. Blood Press Monit
2004;9:24953.
16 Canzanello VJ, Jensen PL, Schwartz GL. Are aneroid sphygmomanometers
accurate in hospital and clinic settings? Arch Intern Med 2001;161:729.
97
Pregnancy BP measurement
39 Ayala DE, Hermida RC. Ambulatory blood pressure monitoring for the early
identication of hypertension in pregnancy. Chronobiol Int 2013;30:
23359.
40 Hermida RC, Ayala DE, Iglesias M. Circadian rhythm of blood pressure
challenges ofce values as the gold standard in the diagnosis of
gestational hypertension. Chronobiol Int 2003;20:13556.
41 Halligan A, OBrien E, OMalley K, Mee F, Atkins N, Conroy R, et al. Twentyfour-hour ambulatory blood pressure measurement in a primigravid
population. J Hypertens 1993;11:86973.
42 Ross-McGill H, Hewison J, Hirst J, Dowswell T, Holt A, Brunskill P, et al.
Antenatal home blood pressure monitoring: a pilot randomised controlled
trial. BJOG 2000;107:21721.
43 The Maternal Critical Care Working Group. Providing Equity of Critical and
Maternity Care for the Critically and Maternity Care for the Critically Ill
Pregnant or Recently Pregnant Woman. London: Royal College of
Anaesthetists; 2011.
44 Singh S, McGlennan A, England A, Simons R. A validation study of the
CEMACH recommended modied early obstetric warning system (MEOWS).
Anaesthesia 2012;67:128.
98