Hypertensive Disorders During Pregnancy Essay Assignment Paper
Hypertensive Disorders During Pregnancy Essay Assignment Paper
Hypertensive disorders of pregnancy (HDP) are multisystem diseases, which include chronic (preexisting) hypertension, gestational hypertension, preeclampsia, eclampsia, and preeclampsia superimposed on chronic hypertension [1]. These disorders may complicate 5%–10% of all pregnancies [2] and are leading causes of maternal and perinatal mortality and morbidity worldwide [3].Hypertensive Disorders During Pregnancy Essay
The high perinatal mortality in women with HDP is mainly due to premature delivery and growth restriction [4, 5]. A secondary analysis from the World Health Organization (WHO) multicountry survey has shown that there were about 3- and 5-fold increased risk of perinatal death in women with preeclampsia and eclampsia, respectively, as compared to women with no preeclampsia/eclampsia [3]. Specifically, the perinatal mortality in women with hypertensive disorders was reported as 230/1000 births from Pakistan [6], 144/1000 births from Turkey [7], 165/1000 births from Addis Ababa [8], and 317/1000 births from Jimma/Ethiopia [9]. Another study, which included only eclamptic mothers, also showed the high perinatal mortality [10].Hypertensive Disorders During Pregnancy Essay
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Although there is a large body of literature that described the magnitude and associated complications of HDP, little is done to assess the predictors of perinatal mortality, particularly in low and middle income countries [11–13]. This is despite the fact that the majority of perinatal deaths due to complications of HDP have occurred in the low and middle income countries [6–10, 14]. Similarly, the authors of this study could not find a published study on HDP in the Southern Regional State of Ethiopia. Furthermore, the authors observed high perinatal mortality in the hospitals where they have been working. This study was planned with an objective of determining the predictors of perinatal mortality among women with HDP.
2. Methods
2.1. Study Setting and Design
This analysis was done using data from three university teaching hospitals in the Southern Regional State of Ethiopia (Hawassa Referral Hospital, Hosanna Hospital, and Yirgalem Hospital) from 2008 to 2013. During this period, a total of 30,750 babies were delivered after 28 weeks of gestational age, of which 1098 women were diagnosed to have HDP. A retrospective cohort study design was used to include the patient’s data from the onset of HDP to the time end of treatment was declared (mother discharged as a cure or for death). This study included all eligible women with HDP admitted to the study hospitals during the study period. The exclusion criteria were baby delivery before 28 weeks of gestation, lost or incomplete data, or mother death on arrival.
2.2. Variables and Data Collection
An association of perinatal mortality was assessed for maternal age, parity, gestational age, antenatal care, number of fetuses, type of HDP, onset of HDP, severity symptoms of HDP, proteinuria, hemoglobin, platelet count, creatinine, serum oxaloacetic transaminase (SGOT) level, labor onset, type of anticonvulsant or antihypertensive given, mode of delivery, fetal birth weight, and maternal outcome.Hypertensive Disorders During Pregnancy Essay
For each study hospital, nine nurse data collectors were recruited and trained. To access the detailed data in the patient chart, the delivery log book was used as an entry point to identify the HDP patients by their card number. A structured data collecting format was prepared and used to abstract relevant data from the included patients’ charts starting from the onset of signs and symptoms of HDP to the time end date was declared.
2.3. Data Processing and Analysis
After completeness was checked, data were coded, entered, and analyzed using computer data analysis software program (SPSS version 20). Bivariate and multivariate regression models were used to estimate the associations between selected predictor variables and perinatal mortality. A statistically significant association was considered when the odds ratio (OR) 95% confidence interval did not include the number 1. Variables which did not show statistical significance in the univariate analysis were excluded from the multivariate analysis.
Hypertensive disorders are the second leading direct cause of maternal death (Lewis, 2007). The report “Saving Mother’s lives” (Lewis, 2007) highlighted the need for medical professionals, including midwives, to immediately recognise and act on the signs and symptoms of life threatening conditions such as pre-eclampsia. The report emphasised a lack of basic clinical skills being one of the leading causes of mortality and highlighted examples where healthcare professionals had misdiagnosed and failed to make routine measurements of blood pressure.Hypertensive Disorders During Pregnancy Essay
The accurate and timely measurement of blood pressure throughout the antenatal period is a key midwifery skill. Whilst a routine practice, midwives need to be vigilant in their approach to ensure early detection of any anomalies and that subsequent management and referral is carried out (Macdonald, 2011). Throughout this essay we will examine the role of blood pressure measurement taking by the midwife, throughout the antenatal period, in identifying the onset of hypertensive disorders and pre-eclampsia. We will consider the importance of establishing a baseline blood pressure, the application of the skill in practice and factors, such as technique and equipment, which may affect the accuracy of the measurements taken. Minimising the impact of these factors will ensure that the measurements observed are as accurate as possible to enable clinical decision making and subsequent care.
Wilson (2005, p.29) defines blood pressure as “the pressure exerted by the blood on the vessel wall”. It is composed of two elements, systolic and diastolic pressure. Systolic pressure is the pressure within the brachial artery during ventricular systole (contraction of the ventricles). Diastolic pressure is the pressure within the artery during ventricular diastole (relaxation of the ventricles).
During pregnancy physiological changes occur in the body which have the direct result of affecting blood pressure. The cardiovascular system must meet the growing demands of the pregnant women and the fetus. As a result cardiac output increases by up to 40%. Changes in vascular activity occur as a result of increased levels of the hormone progesterone acting on the smooth muscle of the vessel walls causing vasodilation (Marshall, 2014). Due to this change during the first and second trimester of pregnancy there is a marked decrease in diastolic blood pressure and a minimal decrease in systolic blood pressure of approx 10mmHg. This can result in tiredness and light headedness for some women during early pregnancy and should be recorded by the midwife during antenatal appointments. Both diastolic and systolic blood pressures should however rise slowly throughout the third trimester to pre-pregnancy levels. Some women do not have the expected reduction in blood pressure during early pregnancy and this may be an early indicator of hypertensive disease in pregnancy (Coad, 2013).Hypertensive Disorders During Pregnancy Essay
During the antenatal period the Midwife is ideally placed to measure the woman’s blood pressure and confirm normality whilst detecting any unexpected deviations. NICE (2014a) best clinical practice advises that blood pressure measurement should be carried out at each antenatal visit in order to screen for pre-eclampsia. Increased frequency of blood pressure measurements should be considered for women who have additional risk factors for pre-eclampsia such as diabetes mellitus type I and obesity.
In order to correctly identify any complications developed during pregnancy, it is important for the midwife to establish a baseline measurement of the women’s blood pressure at the earliest opportunity. Mosby’s Medical dictionary (2008) defines a baseline as ‘the patient’s initial information at assessment against which later tests will be compared’. In the context of measurement of blood pressure the initial measurement taken at the booking appointment (or earlier appointment) will provide the midwife with a baseline of the women’s blood pressure for the duration of the antenatal period. Any unexpected deviations such as significant hypertension will also alert the midwife to the need for increased monitoring throughout the term of the pregnancy. The establishing of a baseline and monitoring over the ante natal period will also aid any other midwives and doctors that take over responsibility of the women’s care at the onset of labour.
The results yielded by accurate blood pressure measurement enable the midwife to effectively monitor and diagnose any potential complications throughout the antenatal period. They play a central role in the screening and management of hypotension and hypertension. The accuracy of these measurements is therefore critical due to the implications if not correct. There are two key factors which will affect the accuracy of blood pressure measurement; the equipment that is used and the technique in which the measurement is taken.
Blood pressure is measured through the use of a sphygmomanometer and these are either auscultatory (manual) or oscillatory (automated). Aneroid manometers (a form of auscultatory sphygmomanometer) are what is commonly used in the community setting due to being lightweight and compact. The method consists of the use of a combination of a stethoscope and an arm cuff which is used to take blood pressure readings. The midwife must listen for the sounds which correlate to systolic and diastolic pressure called Kortokoff sounds. This is a skill which requires training and practice. Automated oscillatory manometers are increasingly used within hospitals, partly due to their ability to be programmed to automatically take blood pressure at set intervals. Oscillatory manometers measure the vibration of blood travelling through the arteries and converts this movement into digital readings (OMRON, N.D). They do not require the use of a stethoscope. When using either type of devices it must be ensured that they have been appropriately validated, maintained and re-calibrated. Turner et al (2006) concluded that a failure to calibrate sphygmomanometers would result in the under and over detection of hypertension by up to 31%. The midwife therefore needs to be assured and is responsible for ensuring that any sphygmomanometer used has been appropriately calibrated and tested. To ensure comparable blood pressure measurements they should also record the type of sphygmomanometer used. Ensuring the use of the correct sized arm cuff when taking a measurement is also very important. Using standard size arm cuffs on obese patients may result in blood pressure’s being overestimated by up to 25% (Waugh & Smith, 2012).Hypertensive Disorders During Pregnancy Essay
With both methods of measuring blood pressure there is a need to provide a relaxed setting, with the individual quiet and seated with their arm supported, palm up and stretched out. Ensuring that their clothing is not constricting the arm in any way. Once the arm is in the correct position the midwife should palpate the radial or brachial pulse before attaching the cuff to ensure correct positioning. Some automated devices will not measure blood pressure accurately if there is pulse irregularity (NCGC, 2011). By palpating the pulse first this will help identify any irregularity and allow for the midwife to switch to using a manual method, if not already, using direct auscultation over the brachial artery (NICE, 2014b). The cuff once in position should be inflated to 20-30 mmHG above the palpated systolic blood pressure and the stethoscope placed over the brachial artery. Deflation of the cuff should begin at a rate of 2 mmHG per second. Reindeers et al (2006) states that deflation of the cuff should not be any faster as this can result in an inaccurate measurement whereby systolic pressure is underestimated and diastolic pressure is overestimated. When clear tapping sounds first appear this is the systolic blood pressure. The diastolic blood pressure is measured at the point at which there is a disappearance of sounds. This is known as Korotkoff V (Bothamley & Boyle, 2008). Readings should be documented immediately and to the nearest 2mmHG. A difference in systolic blood pressure readings between right and left arms >10mmHg may be observed in antenatal women and is considered normal.
The midwife has an important role in screening women for hypertensive disorders during the antenatal period. At the booking appointment the midwife will complete a detailed assessment of the woman’s physical and mental wellbeing and at this stage is able to identify risk factors. To date no screening tests for pre-eclampsia have been recommended for routine use (UK National Screening Committee, 2010). Therefore the identification of risk factors coupled with routine blood pressure measurement and screening for proteinuria at every antenatal appointment are crucial to ensure effective screening for hypertensive disorders. The early diagnosis and referral of hypertension and hypotension reduces the risk of stroke and other complications during pregnancy and the onset of pre-eclampsia. This allows for management of the condition by both doctor and midwife.Hypertensive Disorders During Pregnancy Essay
Individual factors such as existing chronic hypertension, age or BMI put the woman at an increased risk of developing hypertension or pre-eclampsia during her pregnancy. The influence of these factors can be substantial, altering systolic readings as much as 20mmHg (NCGC, 2011). Maternal Body Mass Index (BMI) is a factor that has a significant influence on blood pressures levels during a woman’s pregnancy. Miller et al (2007) observed that trimester specific mean systolic blood pressures were between 10.7-12.0 mmHg higher and mean diastolic blood pressure between 6.9-7.4 mmHg higher, amongst obese women (BMI ≥ 30) v’s lean women (BMI ≤ 20). It is therefore important that maternal BMI is calculated at booking to identify any women classified as being obese. This is of relevance due to the increased incidence of pre-eclampsia and gestational hypertension amongst women with increased BMI (Bhattacharya et al, 2007).
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