Content Files 927b3a1c1356fdc8ec425f53de5b34c5 Predictive Factor and Screening

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REVIEW

Antenatal screening and predicting hypertension in

pregnancy for midwives

Ann S. Peacock a,b,*, Fiona Bogossian a

a The University of Queensland, The School of Nursing and Midwifery, Edith Cavell Building, Herston, Queensland, Australiab

Mater Mothers Research Centre, Level 2, Quarters Building, Mater Health Services, Annerley Road, Woolloongabba,Brisbane, Queensland, Australia

Received 26 June 2009; received in revised form 7 September 2009; accepted 16 September 2009

Introduction

The cause of hypertension in pregnancy remains unknownand results in an increased risk of complications for motherand baby.1 The Society of Obstetric Medicine of Australia andNew Zealand (SOMANZ) classify hypertension in pregnancy aspre-eclampsia (PE), eclampsia, gestational hypertension

Women and Birth (2010) 23, 8193

KEYWORDS

Hypertension;Pregnancy;Prediction;Midwives;Antenatal

Summary

Background: The cause of hypertension in pregnancy remains unknown and results in increased

risk of complications for mother and baby. Symptoms of developing pre-eclampsia, such as an

elevated blood pressure, can be vague and singular. The purpose of this literature review is to

evaluate research investigating antenatal screening practices for hypertension which fall within

the midwives scope of practice.

Method: Inclusion criteria for this literature review were English language, peer reviewed

primary research journal articles, published in the previous 20 years where the population under

study was pregnant with reported outcomes of prevention, screening or prediction of hyperten-

sion in pregnancy. A large number of papers (n = 201) were identified and these were screened and

subsequently excluded if they addressed diagnostic testing, screening and interpretation that

depended solely on a medical practitioner.

Results: There was no single predictive factor found, however the relevant papers included in

this review (n = 33) found evidence of modifiable, non-modifiable and clinical assessment factors

for inclusion in a midwifery screening model.

Conclusions: Further research should be focused on the factors observed by midwives during

history takingand theantenatal coursein thesecond and third trimesters and whether or not these

can be synthesised in to a hypertension-specific diagnostic tool for use in midwifery practice.

# 2009 Australian College of Midwives. Published by Elsevier Australia (a division of Reed

International Books Australia Pty Ltd). All rights reserved.

* Corresponding author at: Mater Mothers Research Centre, Level2, Quarters Building, Mater Health Services, Annerley Road, Wool-loongabba, Brisbane, Queensland 4102, Australia.Tel.: +61 7 3163 1591.

E-mail address: [email protected] (A.S. Peacock).

a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : w w w . e l se v i e r . c o m / l o ca t e / w o m b i

1871-5192/$ see front matter # 2009 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

doi:10.1016/j.wombi.2009.09.002
mailto:[email protected]://dx.doi.org/10.1016/j.wombi.2009.09.002http://dx.doi.org/10.1016/j.wombi.2009.09.002mailto:[email protected]


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(GH), and chronic hypertension. Defined as a disorder thatcombines hypertension with or without proteinuria, PEinvolves one or more organ system whereas GH is the onsetof hypertension after 20 weeks gestation without organinvolvement and returns to normal within 3 months of deliv-ery.2 Although much is known of predisposing factors forhypertension in pregnancy, screening is limited to measure-ment of blood pressure (BP) reading with further investiga-

tions undertaken if PE or GH is suspected. Symptoms ofdeveloping PE, such as an elevated BP, can be vague andsingular.

A number of systematic reviews published on the screen-ing and prevention of PE identify a core group of factors thatcan be used to predict and subsequently help prevent thisdisease. However, these reviews have largely addressedmedical practice. As midwifery-based antenatal carebecomes an increasingly prevalent choice for healthy low-risk women,3 prediction and the early diagnoses of PEbecomes more important, particularly in remote areas orin clinics without access to medical staff.

The purpose of this literature review is to evaluateresearch investigating antenatal screening practices which

fall within the midwifes scope of practice as defined bythe Australian Nursing and Midwifery Councils NationalCompetency Standards and the Australian College of Mid-wives,4 National Midwifery Guidelines for Consultationand Referral.5

Literature search strategy and databasessearched

An electronic database search was performed using Medline,Pub Med, CINAHL, Ebscohost, and Scopus and the Booleanstrategy. Keywords used singularly and in combination

included: pre-eclampsia; screening; trimester (1st and2nd); pregnancy; blood pressure; tests; induced hyperten-sion; pregnancy-induced hypertension; toxaemia; risks;antenatal; and midwives/midwife.

The search strategy involved a three-phase approach.Initially, criteria for inclusion were primary research, pub-lished in English language, in peer reviewed journals withinthe previous 20 years where the population under study waspregnant, with reported outcomes of prevention, screeningor prediction of hypertension in pregnancy. A large number ofpapers (n = 201) were identified under the initial searchterms. A preliminary review of these studies revealed thatmany focused on risk factors, published guidelines and poli-cies, and populations of high-risk women or women with

already diagnosed PE (n = 42) and these were subsequentlyexcluded.

The remaining papers underwent secondary screening,and analysis. Although midwives can refer and implementscreening tests, the diagnoses and interpretation of specificresults including Doppler ultrasonography, and complex hae-matological changes remains outside the midwives currentscope of practice. Those papers involving research outcomesbased on the use of Ultrasonography, predictors based onpathology testing and results, and physical assessment andtesting determined by a medical practitioner were subse-quently excluded (n = 146). Table 2 summarises studiesexcluded in this second phase.

Thirty-three papers which reflected the scope of midwif-ery care practice remained and have been included in thisthird phase of review (Table 1). Factors which increase therisk of GH andPE have been identified from existing literatureand are recognised by SOMANZ (2008). They can be used bymidwives in practice. These include: nulliparity; age greaterthan (>) 40 years; family history of PE in a mother or sister;previous PE; Body Mass Index (BMI) > 25; multiple pregnan-

cies; pre-existing diabetes; and diastolic BP measurementgreater than 80 mmHg at the initial antenatal visit. Theanalysis indicated evidence of modifiable, non-modifiableand clinical assessment factors which may be included in amidwifery model that predicts PE.

Modifiable factors

A modifiable risk factor is one that can be altered withintervention thereby decreasing the risk of the complica-tion it causes. Midwives are at the forefront of informationgathering and using thorough history taking and accurateassessment can identify potential risk factors. The accuracy

of this information is vital to allow the clinician to for-mulate and provide optimal individualised care for motherand baby.

High BMI and its association with PE has been documentedin a systematic review of the risk factors for PE identifiedduring antenatal booking with a BMI > 35 kg/m2 found todouble the risk of developing PE.6 Cnossen et al. performeda bivariate meta-analysis to determine the ability of BMI topredict PE.7 BMI (calculated from both self-reported or firstbooking height and weight) although helpful, was not usefulas a single predictive factor. While reporting bias may be aconsideration in this approach, the work of Mamun et al.demonstrates a strong correlation between the accuracy of

self-reported and booking BMI,

8

suggesting the clinician isable to accept either measurement.A longitudinal study evaluated the relationship between

low BMI in first trimester and the incidence of PE andGH compared with normal and high BMI.9 Women with aBMI < 19.8 kg/m2 had less incidence of GH and PE. How-ever, the cohort of low BMI women were found to beyounger therefore less likely to have underlying conditionsthat predispose to PE. The author offers that this may bedue to the absence of metabolic disorders which canmanifest with increasing BMI and the association of othercomplications such as increased incidence of intrauterinegrowth retardation.

Women often seek advice from midwives regarding diet,

vitamins and exercise during pregnancy in order to establishand maintain a healthy lifestyle for themselves and theirbabies. To offer the best advice, midwives must practice froman evidence-based perspective by being aware of all currentliterature relating to this facet of antenatal care.

Studies which examine diet vary in their methodologicalapproaches and quality. A systematic review on the use ofgarlic for prevention of PE and its complications10 did notprovide an adequate evidence base to be able to recommendincreased garlic intake during pregnancy. The premise thatgarlic may lower blood pressure therefore preventing uterineconstriction associated with PE is an area requiring furtherstudy.

82 A.S. Peacock, F. Bogossian


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A prospective cohort study (n = 1718) examined the asso-ciation of a number of vitamins, fatty acids and calcium withthe development of PE using a food frequency questionnairein the first trimester.11 No significant association for anyparticular diet component was reported however, a potentialbenefit of a regular intake of oily fish (n 3 fatty acids) wasidentified. This was in contrast to a large randomised trialwhich concluded that fish oil had no effect on hypertension in

pregnancy.12

A further study involving food in pregnancy examinedchocolate consumption in early pregnancy and its effecton PE incidence.13 The authors acknowledge that theirresults may suggest chocolate consumption decreases therisk of PE however; the evidence is not strong enough makepublic health recommendations due in part to the possibilityof under and over-reporting of chocolate consumption by theparticipants through self-reported questionnaires.

Midwives are often asked for advice during the course ofantenatal care regarding vitamins and mineral use in preg-nancy. The role of calcium in reducing the incidence of PE hasbeen reported in a number of research studies detailed in aCochrane review.14 It was concluded that adequate dietary

calcium in early pregnancy should be encouraged and thatsupplementation appears to reduce the risk of PE. One studyconcluded calcium supplements reduced the incidence of PEwhere dietary intake of calcium was below recommendedlevels.15 This is relevant to midwifery practice when anobservational study has shown that pregnant women maynot be receiving the recommended intake of calcium throughdiet alone.16

Two randomised controlledtrials proposed that Vitamins Cand E reduced the risk of PE17,18 although neither proved thisto be the case. One study reported Vitamin C and E increasedthe rate of low birth weight babies18 while Theroux sought toassess the association between PE pre-conception multivita-

min use finding further research was required as the resultswere inconclusive.19

Advice regarding exercise and general well-being has longbeen a part of midwifery care to promote positive maternaland baby outcomes. One study examined physical activityand another oral health; both being aspects of health carethat midwives can address with their clients. Osterdal et al.investigated whether physical activity in early pregnancydecreases the risk of PE reporting there was no protectiveeffect observed. Their data demonstrated physical activity inexcess of 270 min/week could increase the risk of developingPE.20 Oral hygiene was researched to investigate if it could beclassed as a risk factor for PE with results showing thatperiodontal disease with systemic inflammation, measured

as C-reactive protein, is associated with increased incidenceof PE.21

These modifiable risk factors have the ability to be alteredbefore and during a pregnancy by the women followingadvice, education and support from the midwife providingantenatal care.

Non-modifiable factors

Non-modifiable risk factors cannot be altered as they arereliant on external factors such as family history, previouspregnancies, age and ethnicity. Midwives are able to identifythese factors during the compilation of the patients history,

Table

1

(Continued)

Includedstudy

Studydesign

Sample

size

Title

Carvalho(2006)

Cohortstudy

29participantsinBrazil

Predictiv

efactorsforpregnancyhypertensioninprimiparous

adolesce

nts

Clinicalassessment

Conde-Agudelo(2004)

Systematicreview

87stud

ies

Screenin

g

Cnossen(2008)

Systematicreview

34stud

ies

MAP

Miller(2007)

Cohortstudy

1,6

55p

articipantsforSweden

andUSA

Firsttrim

estermeanarterialpressureandriskofpreeclampsia

TheHAPOStudy

CooperativeResearch

Group(2008)

Observationalcohort

23,3

16

participantsfrom

16internationalmulticentres

Hypergly

caemiaandadversepregnancyoutcom

es

Tomoda(1994)

Cohortstudy

125par

ticipantsform

Japan

Predictio

nofpregnancy-inducedhypertensionb

yisometricexercise

Baker(1994)

Cohortstudy

200par

ticipantsfrom

UK

Theuse

ofthehandgriptestforpredictingpre

gnancyinduced

hyperten

sion

Watson(1995)

(MeherandDuley,2006)

Cohortstudy

97participantsfrom

USA

Pressorresponsetocycleergometryinthemidtrimesterof

pregnancy:canitpredictpreeclampsia?

Abbreviations:BMI,BodyMassIndex;

RCT,Random

ControlledTrial;MAP,Mean

ArterialPressure.



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providing an opportunity to form an accurate assessment oftheir patient.

Trogstad et al. aimed to estimate the risk of PE in primi-parous women with history of spontaneous and inducedabortions.22 This observational research surveyed 20,846women participating in the Norwegian Mothers and Childstudy. After adjusting for confounders, results showed thattwo or more induced abortions provide similar protection

from PE to that of one previous pregnancy without PE.Concurrent research on the same cohort further investigatedif recurrent miscarriage and infertility contributed to PE.23

Information regarding PE was compared with that of theNorwegian Birth registry and concluded that, when com-bined, the risk factors for infertility and recurrent miscar-riages may contribute to the development of PE. Theexposure data for these studies was based on self-reportedquestionnaires. However, this method of data collection isprone to under and over-reporting of conditions. Some of thecriticisms of this method are confusion in participantsresponses due to understanding of data required and reluc-tance of participants to disclose sensitive information.

Mostello et al. aimed to research the incidence of PE

recurrence by examining the gestational age at delivery ofthe first pregnancy, BMI, paternity (defined as paternalstatus unknown or different from previous pregnancy) andbirth interval in a large population-based cohort study(n = 103,860). Linked by maternal name and date of birth,data from birth and fetal death certificates24 were studied.Increasing BMI and early delivery of previous pregnanciescomplicated by PE both contributed to its risk of recurrencehowever, there was no increased risk identified with changein paternal status. The limitations in the methodology of thestudy include the possible lack of consistency in data input.The death certificates could not include severity of pre-eclampsia and the possibility of under-reporting of under-

lying medical conditions which could contribute to PE wererecognised by the researchers.24

During initial antenatal interview with the midwife,information is collected relating to the womens ethnicity.This information was examined using parental ethnicity anddiscordance to determine the association between thesefactors and PE.25 The retrospective cohort study(n = 127,544) showed a decrease in the rate of PE in popula-tions with Asian paternity. In Australia in 20062007, over25% of immigrants were from Asian countries, making par-ental ethnicity an important component of the antenatalhistory.2

Family history is another integral part of the interview. Asystematic review examined whether a medical history of PE

in mothers and sisters led to a predisposition to PE.6 Inclusionof familial history questions was supported by a large popula-tion-based casecontrol study (n = 10,723),26 whichreported women who developed PE were 2.3 times morelikely to have a sister who also developed PE. However, thisassociation may be confounded by behavioural factors suchas obesity and smoking that might cluster in families.27

Another smaller study (n = 368) discovered that in primigra-vida, a family history of PE is associated with a four-fold riskof severe PE.39

Economic status is an area not necessarily assessed bymidwives unless it is an issue evident for the women they carefor. A cohort study examined whether low socioeconomic

status as a risk factor for PE. Using educational level as anindicator of socioeconomic status,28 results showed thatwomen in the lower socioeconomic group were more likelyto develop PE. However, this finding should be interpretedcautiously. Although the response rate was 68%, lower edu-cated women were less likely to respond. Additionally, theuse of a self-reported questionnaire may have contributed todiffering interpretations of educational status by partici-

pants. The conclusions demonstrated a correlation betweenlow socioeconomic status and PE however, these phenomenawere largely unexplained, so further exploration of anyassociation is needed.

Carvallo et al. performed a small study (n = 29) to examinepredictive factors in adolescents (1619 years) and thedevelopment of PE.29 Results showed the best predictorsof this condition were family history and diastolic bloodpressure measurements at differing periods of the day, how-ever further research with a larger cohort is needed to verifythese results.

These factors are unable to be altered during pregnancy;however reinforcement of their importance during theantenatal period can be stressed by midwives. This informa-

tion, in combination with both modifiable and clinical assess-ment factors can be used to help identify patients at higherrisk of developing PE.

Clinical assessment

In 2004, the World Health Organisation conducted a systema-tic review assessing all tests used to prediction PE, and foundthat there is no definitive, low-cost, predictive test avail-able.30 Another extensive systematic review highlightednumerous risk factors for hypertension in pregnancy how-ever; many screening strategies such as the presence ofantiphospholipid antibodies and interpreting Doppler-based

measurements are beyond the current scope of practice ofthe midwife. Most recognised risk factors which contribute toPE would result in the pregnancy being categorised as high-riskwhich, according to National Midwifery Guidelines forConsultation and Referral, would require obstetric-ledantenatal care. Hence, this is beyond the scope of practiceof the midwife.6

Blood pressure measurement remains one of the mostdefinitive predictors of PE and is a key component ofantenatal assessment at each visit.31 Duckitt reviewed fourstudies, all examining BP readings, and concluded that asystolic blood pressure of >130 doubled the risk of PE.Additionally, this review also showed that initial or bookingBP was a vital component to give insight to prediction of

PE.6 The gold standard of measurement of blood pressure isthe mercury sphygmomanometers2,38; however standar-dised practice should be employed by practitioners toavoid possible inaccurate readings. The woman shouldbe seated comfortably with her legs resting on a flatsurface. The systolic blood pressure is accepted as thefirst sound heard and the diastolic blood pressure thedisappearance of sounds completely. Correct cuff size isimportant for accurate blood pressure recording, with alarger cuff used if the upper arm circumference is greaterthan 33 cm [2, p. 4].

If automated devises are used then it is vital that theyare checked and calibrated at least monthly to maintain



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accuracy and used according to manufacturers specifica-tions. A large international research project which wasreliant on BP measurement by automatic machines insixteen centres alleviated the potential for inconsistencyby providing each centre with an identical machine, withmonthly checking by the research team with mercurysphygmomanometers to detect any discrepancies invalues.31

A retrospective cohort study examinedif the combinationof BMI and high-normal BP can be used as a predictor.32 Theresults showedthat being overweight or obese may notbe anindependent risk factor for development of PE comparedwith just having high-normal BP; however, this study notedthat further research is necessary before conclusions can bemade.

A systematic review and meta-analysis was completedon the accuracy of mean arterial pressure (MAP) and BPmeasurements and their predictive qualities, and foundthat the MAP was a better predictor than BP alone.33 MAPcould therefore be used by midwives during their routineantenatal care. Miller et al. used a prospective cohort(n = 1655) and found that although first trimester MAP is

strongly associated with increased risk of developing PE, itwill not predict with accuracy those women who willdevelop PE.34 Cnossen et al. in their systematic reviewof 34 studies (n = 60,599) explored the accuracy of usingsystolic/diastolic BP, mean BP, and increasing BP to predictPE and found that MAP was in fact a better predictor.Further research is recommended to develop algorithmsthat combine all predictive factors in order to identifywomen who will develop PE.33

A large research study (n = 25,505) recently examined theeffects of maternal glucose levels and adverse outcomes.31

They found that there was an association with glucose levelslower than the diagnostic level for diabetes and the inci-

dence of PE in both fasting and 2 h results.Research by several authors relating to physical testing ofhand grip and BP response to exercise has been conducted toattempt to predict PE using non-invasive interventions.Tomoda tested women by a use of a hand grip test bymeasurement of systolic pressure,35 Baker by hand gripalone,36 and Watson by aerobic exercise to increase heartbeat up to 140 beats/min.37 Although these tests are able tobe performed within the midwives scope of practice, thereliability of operator, the amount of time required andunpredictable nature of the test does not lend itself tointroduction to routine testing.

Accurate clinical assessment is essential to provideongoing antenatal care in the second and third trimester.

Midwives may be able to assess all facets of the antenatalcourse, including oral glucose tolerance tests, blood pressurereadings, and reviewing previously documented history toidentify women at risk with the use of tool designed tocorrelate this information. This is important as timely refer-ral has been a key component in reducing maternal andneonatal morbidity.1 Treatment of hypertensive disordersonce diagnosed remains outside the midwives scope of prac-tice,5 but as elevated BP is often the first clinical indicator ofPE, midwives are obligated to refer the woman for furtherinvestigations and treatment according to guidelines set bymedical organisations such as SOMANZ2 and Australian Col-lege of Midwives.5

Discussion

This literature review aimed to identify predictors ofhypertension in pregnancy that could be used by midwivesin their scope of practice. The important role of obtainingan accurate medical, family and obstetric history is pre-dominately that of the booking midwife. There are numberof factors that can be assessed at this time that have shown

to reflect the womens predisposition to development ofPE. Physical baseline characteristics such as BMI, age andblood pressure measurement need to be documented accu-rately.

These assessments can be complemented by informa-tion relating to paternity, and ethnicity. Family history hasbeen reinforced as a risk factor, indicating the need to askcomprehensive questions regarding mothers and sistershistory relating to PE which can alert the midwife topossible association to developing PE. The initial historyappointment needs to be completed both comprehensivelyand thoroughly, so all relevant information is gathered andassessed, allowing the care giver to formulate an individualcare pathway.

Advice given to clients by midwives regarding health andwell-being has always been a necessary part of antenatalcare. The studies that have been reviewed here did notidentify any singular factor that would decrease the risk ofPE, however regular exercise, a healthy diet rich in calciumand omega 3 may not only be helpful for prevention of PE, butoverall good health for mother and baby and therefore couldbe safely recommended by midwives.

The need for early referral to medical staff from mid-wifery-based care of complicated pregnancies to helpdecrease the long term detrimental effects of hypertensionin pregnancy has been well documented and midwives needto be vigilant during their clients antenatal course. Midwives

within their scope of practice have the opportunity to bothidentify and predict PE and are in a position to identify riskfactors and thereby provide the best possible care for theirmothers and babies.

Conclusion

Hypertension in pregnancy is a condition that concerns allmaternity care providers. Midwives are in the unique positionof gathering data from the initial presentation of the womenfor antenatal care and continuing through the antenatalcourse. This review found 33 papers that specificallyaddressed prevention, screening and prediction of PE within

the scope of practice of the midwife. Reviewing researchrelating to modifiable factors, non-modifiable factors andclinical assessment provides a useful framework for gatheringinformation that could predict PE such as family history,parity, previous pregnancy details and highlights the impor-tance of accurate and timely assessment of BP, BMI, OGTTandfetal assessment which may prove vital for the early predic-tion of PE. This review focused on healthy low-risk women,women who would not automatically be referred for earlytesting or monitoring, but could screened for hypertension inpregnancy by midwives. Further research should focused onthe factors assessed by midwives during history taking andthe antenatal period and whether or not these can be

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synthesised in to a hypertension-specific diagnostic tool foruse by midwives in practice.

Acknowledgments

The author would like to acknowledge Mater MothersResearch Centre and Golden Casket Midwifery ResearchScholarship for research and funding support.

The author would also like to thank Susan Kellet for helpwith editing.

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