Sei sulla pagina 1di 8

DOI: 10.1111/tog.

12173

2015;17:918

Review

The Obstetrician & Gynaecologist


http://onlinetog.org

Blood pressure measurement in pregnancy


Hannah L Nathan MBBS BSc DFSRH,a Kate Duhig MBBS BSc MRCP,b Natasha L Hezelgrave
Lucy C Chappell MBBS PhD,c Andrew H Shennan MBBS MD FRCOGd,*

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

Accepted on 8 January 2015

Key content

Learning objectives

Accurate blood pressure (BP) measurement is fundamental to early


diagnosis of hypertensive disorders in pregnancy.
 Poor auscultatory technique and lack of training leads to
inaccuracies in BP measurement using sphygmomanometry with
mercury and aneroid devices.
 Automated devices limit user error but require validation of
accuracy because they tend to underestimate BP
in pre-eclampsia.
 Systolic hypertension may better predict risk of adverse outcome
(such as haemorrhagic stroke) than diastolic hypertension.
 Ambulatory/self-monitoring increases the number of
representative readings available on which to base management,
limiting unnecessary intervention.
 Detection of hypotension in pregnancy is crucial to the diagnosis
of shock secondary to haemorrhage and sepsis.

To learn how to obtain accurate BP measurements in pregnancy.


To understand the significance of hypertension in pregnancy.

Ethical issues


A large proportion of maternal deaths are associated with


substandard care, often related to poor recognition of severity of
hypertension or shock and need for treatment.
 Lack of cheap, accurate, easy-to-use BP devices in low- and
middle-income countries, where risk of maternal and perinatal
mortality and morbidity secondary to pre-eclampsia and shock is
highest, continues to be a challenge.
Keywords: blood pressure measurement / diagnosis /

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

2015 Royal College of Obstetricians and Gynaecologists

although this figure may be higher when the contribution


of hypertensive disorders in pregnancy to other causes of
mortality (such as postpartum haemorrhage) is considered.
Pre-eclampsia also contributes to one-fifth of all preterm
births globally (and is the leading cause of iatrogenic preterm
birth) and one-quarter of stillbirths and neonatal deaths
in LMICs.1
Accurate measurement of blood pressure (BP) is crucial to
the diagnosis and management of hypertensive disorders in
pregnancy. BP monitoring is the most important, and
frequent, screening test in the antenatal period and is
undertaken by healthcare assistants, midwives, general
practitioners and obstetricians on a daily basis. Accuracy of
BP measurement impacts on maternal and perinatal clinical
outcomes, highlighted in the 20062008 UK Confidential

91

Pregnancy BP measurement

Enquiries into Maternal Deaths report,4 which found that the


most common reason for substandard care in deaths
secondary to pre-eclampsia/eclampsia was failure to
recognise and treat hypertension.
As well as detecting hypertension, BP devices are also
essential for the detection of acute haemodynamic
compromise and management of shock in pregnancy.
Obstetric haemorrhage, pregnancy-related sepsis and unsafe
termination of pregnancy are major contributors to
approximately 46% of maternal deaths worldwide and all
can present with signs and symptoms of shock.3 According to
the Confidential Enquiries report,4 the majority of maternal
deaths could have been avoided if early warning signs of
impending collapse had been recognised and acted on earlier.
Thus, the ability to measure BP accurately is an indispensible
skill for obstetricians, midwives and other healthcare
workers, regardless of setting, in order to prevent maternal
and perinatal morbidity and mortality, both in the UK
and worldwide.
This review considers the importance of accuracy of
BP measurement, including choice of device, technique
and common errors. It also discusses the evidence-based
hypertension BP thresholds at which there is increased
risk of morbidity and mortality in pregnancy, and the
importance of prompt medical intervention, as well as
the role of vital sign monitoring in women at risk
of shock.

Accuracy of BP measurement in pregnancy


BP measurement is a key part of the assessment of
hypertensive disorders in pregnancy, guiding diagnosis,
admission, antihypertensive treatment and timing of
delivery, as well as the assessment of haemodynamic shock
in pregnancy, secondary to obstetric haemorrhage or sepsis.
It is therefore important that all healthcare providers are
aware of the issues surrounding accuracy of BP measurement
in pregnancy.

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

because of inadequate training and equipment, time


constraints or lack of awareness of the importance of BP
monitoring as a screening and diagnostic test.

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.

Sources of error associated with auscultatory


technique
BP measurement using the auscultatory technique relies on
accurate transmission and interpretation of Korotkoff
sounds.
Although
auscultation
using
mercury
sphygmomanometry has been the gold standard of BP
measurement in the past, clinicians are gradually moving
away from such sphygmomanometers because of health and
environmental concerns regarding the use of mercury in
clinical settings. As of 2014, mercury sphygmomanometers
are banned and can no longer be purchased in Europe
because of environmental concerns.
Some non-automated BP devices require regular
calibration to ensure a leak rate (loss of air pressure)
within 4 mmHg/minute and a pressure scale accurate to
within 3 mmHg for any part of the pressure range.9
Observational studies assessing the calibration of BP devices
used in clinical practice demonstrated that 2025% of devices
used in hospital and clinic settings had unacceptable
calibration errors.9,10 Despite recommendations to record
BP to the nearest 2 mmHg, a questionnaire-based study
reported that only 10% of midwives and obstetricians
recorded BP to the nearest 2 mmHg, with 23% recording
BP to the nearest 10 mmHg.11 A study assessing BP values in
women seen at antenatal clinic showed that 78% of readings
obtained by clinicians ended in a zero.12 This user preference
to round off BP values to a zero or five is referred to as

2015 Royal College of Obstetricians and Gynaecologists

Nathan et al.

terminal digit preference and is a source of error associated


with auscultation. Observer bias refers to the user adjusting
the BP reading to what is preferred or what it was
preconceived to be. This concept can extend to threshold
avoidance, where the observer adjusts the BP reading to avoid
thresholds that entail making a diagnosis or requiring
intervention. Again, this is a source of error more
commonly associated with auscultation.

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

Oscillometry: an alternative to the auscultatory


technique
The auscultatory technique for measuring BP requires skill
and training, and is therefore prone to observer error. In
recent years, there has been a shift towards the use of
automated BP devices, which rely on detecting changes in the
amplitude of the intra-arterial oscillometric waveforms
produced during cuff deflation to determine BP. The Royal
College of Obstetricians and Gynaecologists (RCOG), the
British Hypertension Society and a number of international
organisations have recommended that automated devices are
independently validated according to a recognised protocol
to ensure accuracy (for example, the Association for the
Advancement of Medical Instrumentation criteria, British
Hypertension Society and International protocols).17,18
Despite this recommendation, of the hundreds of
commercially available automated devices, only a small
number have been evaluated and even fewer have
passed validation.
The issue of accuracy is even more important for those
devices used in pregnancy. The majority of devices validated
specifically in pregnant populations fail the protocol

2015 Royal College of Obstetricians and Gynaecologists

requirements, likely because of the haemodynamic changes


of pregnancy. A particular concern is that automated devices
tend to underestimate BP in women with pre-eclampsia,
resulting in false classification of normotension in these
high-risk women.19 This is thought to be due to specific
pathological changes of pre-eclampsia, including decreased
arterial vascular compliance and increased interstitial
oedema, which may affect the amplitude and detection of
the oscillometric waveform.20 Separate validation in
pregnancy
(including
pre-eclampsia)
is
therefore
recommended but only a small number of devices have
passed validation for use in pregnancy, which includes
pre-eclampsia (Box 1).
For those automated devices that are validated for use in
pregnancy (including pre-eclampsia), the obvious benefit
over auscultation (mercury sphygmomanometry and

Box 1. Automated devices validated for use in pregnancy (including


pre-eclampsia)










OMRON MIT Elite


OMRON MIT
OMRON Hem 705CP
OMRON M7
Microlife WatchBP Home
Microlife BP 3BTO-A
Microlife BP 3AS1-2
Welch Allyn Spot Vital Signs
Dinamap ProCare 400

http://www.dableducational.org/sphygmomanometers/
devices_1_clinical.html#ClinTable

aneroid) is that inaccuracies secondary to observer error


are limited and BP measurement is simpler. In LMICs,
community healthcare providers caring for women
antenatally may have had limited training in BP
measurement. In these settings, automated devices may be
a more practical alternative. However, there are issues
regarding cost, powering and maintenance of these devices.

Appropriate BP cuff size


To ensure accuracy it is important to consider the size of BP
cuff used, particularly as obesity is a risk factor for
pre-eclampsia and therefore those with a large arm
circumference (33 cm or above) are at higher risk of
developing pre-eclampsia. In a clinical setting large cuffs
are often less readily available than standard cuffs. If the
appropriately sized cuff is not available, that is, if a standard
cuff is used on a woman with an arm circumference of more
than 32 cm, BP can be overestimated.21 Conversely, if a large
cuff is used on a woman with a normal arm circumference,
BP can be underestimated, although this error is much less.22
It is therefore important that a variety of cuffs are available in

93

Pregnancy BP measurement

the clinical setting and that arm circumference is correctly


estimated or measured. If in doubt, overcuffing (using a cuff
that is too large for the arm circumference) is better than
undercuffing (using a cuff that is too small for the
arm circumference).

Evidence-based hypertension thresholds


Obstetricians use BP values to guide management in women
with hypertensive disorders in pregnancy. If BP is
underestimated or overestimated through inaccurate
measurement, avoidable maternal and perinatal mortality
and morbidity can result. Furthermore, obstetricians use BP
thresholds recommended by national guidelines to aid in
management decision making. If these thresholds are not
supported by adequate evidence, maternal and perinatal
mortality and morbidity can again result. The NICE23
guidelines on hypertension in pregnancy define mild
hypertension as diastolic BP of 9099 mmHg and/or
systolic BP 140149 mmHg, moderate hypertension as
diastolic BP 100109 mmHg and/or systolic BP
150159 mmHg, and severe hypertension as diastolic BP of
110 mmHg or above and/or systolic BP of 160 mmHg or
above. Although these definitions are concise and widely
adopted, the BP thresholds that indicate the need for
treatment are less clearly defined.

BP thresholds for treating severe hypertension


For women with severe hypertension, there is consensus that
antihypertensive treatment should be given to reduce the risk
of maternal central nervous system complications, but the
specific thresholds for initiating treatment are based on
limited evidence.
A landmark (yet small) retrospective cohort study of 28
women who sustained strokes in association with severe
pre-eclampsia or eclampsia showed that all women had a
systolic BP of more than 155 mmHg immediately before the
stroke, whereas only 13% had a diastolic BP of at least
110 mmHg.24 A retrospective cohort study of women with
eclampsia showed that posterior reversible encephalopathy
syndrome, defined as the presence of neurological symptoms
and signs, together with radiological findings of vasogenic
cerebral oedema, occurred at lower systolic BP levels in
pregnancy (mean peak systolic BP of 173 mmHg), compared
with non-pregnant patients with hypertensive encephalopathy
(mean peak systolic BP of 191 mmHg).25 These studies
highlight the importance of prioritising the control of
systolic BP over diastolic BP, and support the 2010 NICE
guidelines recommending immediate treatment if systolic BP
is 150 mmHg or above.23 The 2010 NICE guidelines also
recommend immediate treatment if diastolic BP is at least
100 mmHg, although this is largely based on extrapolation of
risk, rather than direct evidence.23 However, a 2012 nested

94

casecontrol study investigating potential factors associated


with antenatal stroke demonstrated that after adjustment for
age, stroke increased by 3% (adjusted OR 1.03, 95% CI 1.00
1.05) for every mmHg increase in highest recorded systolic BP,
compared with 8% (adjusted OR 1.08, 95% CI 1.031.13) for
every mmHg increase in diastolic BP.26

BP thresholds for treating mild-to-moderate


hypertension
There is a lack of consensus among the obstetric community
regarding the threshold of treatment for mild-to-moderate
hypertension in pregnancy. A 2014 update of the Cochrane
review assessing the effects of antihypertensive treatment of
mild-to-moderate hypertension during pregnancy (including
those with a diagnosis of pre-eclampsia)27 demonstrated a
reduction in the number of women developing severe
hypertension or requiring a second treatment agent.
However, well-powered studies demonstrating reductions in
adverse clinical outcome (maternal stroke, progressive renal
and other end-organ disease, and heart failure) following
antihypertensive treatment in these cases are limited.
Similarly, the review failed to demonstrate a significant
effect on preterm births or caesarean sections in those given
antihypertensives. The review concluded that it remains
unclear whether treatment of mild-to-moderate hypertension
is worthwhile. Current NICE/RCOG guidelines therefore do
not recommend treating hypertension of systolic BP of
140149 mmHg or diastolic BP of 9099 mmHg, except in
those women with target-organ damage secondary to
chronic hypertension.23

BP thresholds for treating postpartum hypertension


A 2005 Cochrane review on the management of postpartum
hypertension28 demonstrated insufficient evidence to form
robust recommendations on the thresholds for treatment.
The NICE guidance23 recommends initiating treatment at the
same thresholds as for during the antenatal and intrapartum
period; this is largely based on expert opinion. A 2013 clinical
review29 summarises the evidence for treatment options for
postpartum hypertension and provides a flow diagram with
management pathways.

No role for isolated incremental rise in BP


The use of an isolated incremental rise in BP to define
hypertension in pregnancy is now not recommended in the
guidelines.23 Research has demonstrated that women with an
incremental rise (for example, 30 mmHg systolic BP/
15 mmHg) from booking whose BP remained under the
threshold of 140/90 mmHg had normal pregnancy outcomes.30

Future research to improve evidence base


In response to a call for more robust evidence, an
international multicentre randomised controlled trial on

2015 Royal College of Obstetricians and Gynaecologists

Nathan et al.

the management of mild-to-moderate hypertension in


pregnancy (Control of Hypertension in Pregnancy [CHIPS]
study) is in progress and preliminary results are available.31
Women with non-proteinuric hypertension were randomised
to either tight (target diastolic BP 85 mmHg) or less tight
BP control (target diastolic BP 100 mmHg). There were
similar rates of the primary (perinatal) outcome (a composite
of pregnancy loss or high-level neonatal care for more than
48 hours in the first 28 days of life) between the two groups
(less tight [31.4%] versus tight [30.7%]; adjusted OR 1.02,
95% CI 0.771.35) and secondary outcomes (one or more
serious maternal complications) (3.7% versus 2.0%,
respectively; adjusted OR 1.74, 95% CI 0.793.84) between
the two groups. However, women receiving less tight
control were more likely to develop severe hypertension
(less tight [40.6%] versus tight [27.5%]; adjusted OR 1.80,
95% CI 1.352.38). Therefore it is suggested that treatment to
a target diastolic BP of 85 mmHg is optimal, considering the
risk of adverse cerebrovascular outcomes at higher
systolic BP.31

Recommended lower limit of diastolic BP


The NICE guidelines23 recommend keeping diastolic BP
above 80 mmHg during pregnancy in women receiving
antihypertensive treatment, owing to the concern that
overtreated hypertension could compromise uteroplacental
and fetal circulation, and lead to an increase in small-forgestational-age infants. This recommendation is supported
by a meta-regression analysis of the relationship between
feto-placental growth and use of antihypertensives,
demonstrating that a 10 mmHg fall in BP was associated
with a 145g decrease in birthweight.32 However, concern has
been raised regarding the meta-regression design, which is
prone to all the biases of observational studies.27 In contrast,
the Cochrane review on mild-to-moderate hypertension in
pregnancy27 demonstrated no overall effect on the relative
risk (RR) of having a small-for-gestational-age baby (RR
0.97; 95% CI 0.801.17) in those receiving antihypertensive
treatment compared with placebo.

The use of mean arterial pressure


Evidence is conflicting regarding the utility of mean arterial
pressure (MAP) in pregnancy. A 2008 predictive accuracy
systematic review and meta-analysis demonstrated that MAP
measured in the first and second trimester of pregnancy may
be a better predictor of pre-eclampsia (area under the
receiver operator curve (AUROC) 0.76 (95% CI 0.700.82)
than systolic BP (0.68; 95% CI 0.640.72) or diastolic BP
(0.66; 95% CI 0.590.72).33 Despite this, the AUROC value is
modest and lack of familiarity with MAP thresholds and the
difficulty in obtaining MAP from many devices makes its
clinical utility limited. This is reflected in the current NICE

2015 Royal College of Obstetricians and Gynaecologists

guidelines,23 which do not refer to MAP for diagnosing or


treating hypertensive disorders in pregnancy. Further studies
are required to better establish the predictive value of MAP in
hypertensive disorders in pregnancy and the thresholds that
should trigger intervention.

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

Importance of vital sign monitoring in the


diagnosis and management of obstetric
haemorrhage and sepsis
Obstetric haemorrhage, sepsis and unsafe abortion contribute
to almost half of all maternal deaths globally, the majority of
which occur in LMICs.3 However, our understanding of
haemodynamic changes during pregnancy, delivery and

95

Pregnancy BP measurement

postpartum, and the pathophysiological response


compromise in these conditions remains limited.

to

Modied early obstetric warning score


charts
The 20062008 Confidential Enquiries report4 suggested
that many maternal deaths could be prevented by more
timely detection and intervention in haemodynamic
compromise. This report, as well as the 2011 statement
from the UK Maternal Critical Care Working Group,
recommended the use of a modified early obstetric
warning score (MEOWS) chart for all pregnant and
postpartum women in order to trigger intervention in
those at risk of haemodynamic compromise.4,43 Despite
this recommendation, a national standardised chart does
not exist and there is concern that pregnancy-specific
evidence supporting the vital sign thresholds used on these
charts (particularly BP and pulse) is lacking.44 Only in
2012 was the most commonly used MEOWS chart first
evaluated, demonstrating adequate value for predicting
maternal morbidity but suggesting that further refinements
were required.44 These refinements will only be possible if
there is a research focus on robust pregnancy-specific
validation studies of the vital sign thresholds used on
MEOWS charts.

Conventional vital signs as predictors of


adverse clinical outcome
A healthy woman can lose up to 30% of her blood volume
before a change in systolic BP becomes apparent,
misleading the healthcare provider as to haemodynamic
stability and delaying vital interventions.45 A 2013
systematic review examining the relationship between
blood loss and clinical signs in obstetric haemorrhage
found that pulse and systolic BP, commonly used to assess
haemodynamic status, were poor predictors of blood loss,
likely due to the physiological compensatory mechanisms of
pregnancy.46 Relying on conventional vital signs to prompt
diagnosis and treatment of shock may contribute to
avoidable morbidity and mortality.47,48 This is especially
problematic in some LMIC settings, where the limited
resources available may not be adequate to prevent
mortality and significant morbidity when haemodynamic
instability is eventually recognised.

Shock Index as a marker of haemodynamic


instability
Shock Index, the ratio of pulse to systolic BP, has been
proposed in a nonpregnant and, more recently, a pregnant
population, as an earlier marker of compromise than

96

conventional vital signs. A systematic review has


demonstrated that Shock Index was an accurate indicator
of decompensation in both non-pregnant individuals and
pregnant women (with AUROCs ranging 0.770.84,
compared with 0.560.74 for pulse and 0.560.79 for
systolic BP).46 However, to date, only two retrospective
studies have attempted to define the normal range of Shock
Index in women with obstetric haemorrhage according to
risk of adverse clinical outcome. Both studies concluded that
the upper limit of normal Shock Index was 0.9,49,50 and one
of the studies also suggested a second threshold of at least 1.7
indicating the need for urgent attention.50 The use of Shock
Index in the assessment of women with shock secondary to
obstetric haemorrhage or sepsis may help more promptly
identify those at risk of avoidable mortality and morbidity,
but more studies in this area are required.

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.

2015 Royal College of Obstetricians and Gynaecologists

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.

2015 Royal College of Obstetricians and Gynaecologists

17 OBrien E, Atkins N, Stergiou G, Karpettas N, Parati G, Asmar R, et al.


European Society of Hypertension International Protocol revision 2010 for
the validation of blood pressure measuring devices in adults. Blood Press
Monit 2010;15:2338.
18 OBrien E, Petrie J, Littler W, de Swiet M, Padeld PL, Altman D, et al. The
British Hypertension Society protocol for the evaluation of blood pressure
measuring devices. J Hypertens 1993;11(Suppl 2):S4362.
19 Natarajan P, Shennan A, Penny J, Halligan A, De Swiet M, Anthony J.
Comparison of auscultatory and oscillometric automated blood pressure
monitors in the setting of preeclampsia. Am J Obstet Gynecol
1999;181:120310.
20 Reinders A, Cuckson AC, Lee JT, Shennan AH. An accurate automated blood
pressure device for use in pregnancy and pre-eclampsia: the Microlife 3BTOA. BJOG 2005;112:91520.
21 Fonseca-Reyes S, de Alba-Garca JG, Parra-Carrillo JZ, Paczka-Zapata JA.
Effect of standard cuff on blood pressure readings in patients with obese
arms. How frequent are arms of a large circumference? Blood Press Monit
2003;8:1016.
22 Oliveira SMJV, Arcuri EA, Santos JLF. Cuff width inuence on blood pressure
measurement during the pregnant-puerperal cycle. J Adv Nurs
2002;38:1809.
23 National Institute for Health and Care Excellence. Hypertension in
Pregnancy: The Management of Hypertensive Disorders During Pregnancy.
NICE clinical guideline 107. London: NICE; 2010.
24 Martin JN Jr, Thigpen BD, Moore RC, Rose CH, Cushman J, May W.
Stroke and severe preeclampsia and eclampsia: a paradigm shift
focusing on systolic blood pressure. Obstet Gynecol 2005;105:
24654.
25 Wagner SJ, Acquah LA, Lindell EP, Craici IM, Wingo MT, Rose CH, et al.
Posterior reversible encephalopathy syndrome and eclampsia: pressing the
case for more aggressive blood pressure control. Mayo Clin Proc
2011;86:8516.
26 Scott CA, Bewley S, Rudd A, Spark P, Kurinczuk JJ, Brocklehurst P, et al.
Incidence, risk factors, management, and outcomes of stroke in pregnancy.
Obstet Gynecol 2012;120(2 Part 1):31824.
27 Abalos E, Duley L, Steyn DW. Antihypertensive drug therapy for mild to
moderate hypertension during pregnancy. Cochrane Database Syst Rev
2014;(2):CD002252.
28 Magee L, Sadeghi S. Prevention and treatment of postpartum hypertension.
Cochrane Database Syst Rev 2005;(1):CD004351.
29 Bramham K, Nelson-Piercy C, Brown MJ, Chappell LC. Postpartum
management of hypertension. BMJ 2013;346:304.
30 North RA, Taylor RS, Schellenberg JC. Evaluation of a denition of
pre-eclampsia. Br J Obstet Gynaecol 1999;106:76773.
31 Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al.
Less-tight versus tight control of hypertension in pregnancy. N Engl J Med
2015;372:40717.
32 von Dadelszen P, Ornstein MP, Bull SB, Logan AG, Koren G, Magee LA. Fall
in mean arterial pressure and fetal growth restriction in pregnancy
hypertension: a meta-analysis. Lancet 2000;355:8792.
33 Cnossen JS, Vollebregt KC, Vrieze Nd, Gt Riet, Mol BW, Franx A, et al.
Accuracy of mean arterial pressure and blood pressure measurements in
predicting pre-eclampsia: systematic review and meta-analysis. BMJ
2008;336:111720.
34 Stergiou GS, Asayama K, Thijs L, Kollias A, Niiranen TJ, Hozawa A, et al.
Prognosis of white-coat and masked hypertension: International Database
of HOme blood pressure in relation to Cardiovascular Outcome.
Hypertension 2014;63:67582.
35 Brown MA, Mangos G, Davis G, Homer C. The natural history of white coat
hypertension during pregnancy. BJOG 2005;112:6016.
36 Hermida RC, Ayala DE, Mojon A, Fernandez JR, Alonso I, Silva I, et al. Blood
pressure patterns in normal pregnancy, gestational hypertension, and
preeclampsia. Hypertension 2000;36:14958.
37 Redman CW, Beilin LJ, Bonnar J. Reversed diurnal blood pressure
rhythm in hypertensive pregnancies. Clin Sci Mol Med Suppl
1976;3:687s689s.
38 Peek M, Shennan A, Halligan A, Lambert PC, Taylor DJ, De Swiet M.
Hypertension in pregnancy: which method of blood pressure
measurement is most predictive of outcome? Obstet Gynecol
1996;88:10303.

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

45 Troiano N, Harvey C, Chez B. Massive Post Partum Hemorrhage. In:


AWHONNs High Risk and Critical Care Obstetrics. Philadelphia: Lippincott,
Williams & Wilkins; 2012.
46 Pacagnella RC, Souza JP, Durocher J, Perel P, Blum J, Winikoff B, et al. A
systematic review of the relationship between blood loss and clinical signs.
PLoS One 2013;8:e57594.
47 Birkhahn RH, Gaeta TJ, Van Deusen SK, Tloczkowski J. The ability of
traditional vital signs and shock index to identify ruptured ectopic
pregnancy. Am J Obstet Gynecol 2003;189:12936.
48 Hick JL, Rodgerson JD, Heegaard WG, Sterner S. Vital signs fail to correlate
with hemoperitoneum from ruptured ectopic pregnancy. Am J Emerg Med
2001;19:48891.
49 Le Bas A, Chandraharan E, Addei A, Arulkumaran S. Use of the obstetric
shock index as an adjunct in identifying signicant blood loss in patients
with massive postpartum hemorrhage. Int J Gynaecol Obstet
2013;124:2535.
50 Nathan H, El Ayadi A, Hezelgrave N, Seed P, Butrick E, Miller S, et al. Shock
index: an effective predictor of outcome in postpartum haemorrhage?
BJOG 2015;122:26875.

2015 Royal College of Obstetricians and Gynaecologists