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Pregnacy Induced Hypertension (PIH) Case Study

pregnancyinducedhypertension case study

Pregnancy-induced hypertension (PIH) is one of the most common complications of pregnancy. This occurs during the 20 th week of gestation or late in the second trimester of pregnancy. This is a health condition wherein there is a rise in the blood pressure and disappears after the termination of pregnancy or delivery. PIH was formerly called toxaemia or the presence of toxins in the blood. This is because its occurrence was not well understood in the clinical field. Its common manifestations are hypertension, proteinuria (presence of protein in the urine), and edema. There are 2 main types of pregnancy-induced hypertension namely: pre-eclampsia and eclampsia.

  • Pre-eclampsia— this is the non-convulsive form of PIH. This affects 7% of all pregnant women. Its incidence is higher in lower socio-economic groups. It may be classified either mild or severe.
  • Eclampsia— this is the convulsive form of PIH. It occurs with 5% of all pre-eclampsia cases. The mortality rate among mothers is nearly 20% and fetal mortality is also high due to premature delivery.

NORMAL ANATOMY AND PHYSIOLOGY

There are a lot of bodily changes that happen during a normal pregnancy. There are external changes that are noticeable, and there are internal changes that can only be appreciated through thorough clinical examinations. Most of the changes are the body’s response to the changes in levels of hormones and the growing demands of the fetus.

The two dominant female hormones, estrogen and progesterone , change in a normal level. Along with this, a significant rise/appearance of 4 more major hormones take place; these are 1. human chorionic gonadotropin (HCG), 2. human placental lactogen, 3. prolactin, and 4. oxytocin. All these 6 hormones interact with each other simultaneously to maintain a normal pregnancy as it progresses.

The following are the major effects of these hormones in the body:

The exact cause of pregnancy-induced hypertension is unknown; however, it is highly linked to angiotensin gene T235 and the existence of other risk factors. Malnutrition and inadequate prenatal care are the greatest risk factors. The history and presence of diabetes mellitus (DM), multifetal gestation (twin pregnancies), polyhydramnios (excessive amniotic fluid), and renal diseases are also among the major contributory factors in the development of PIH. In the past, the mystery revolving around PIH postulated a lot of theories on its true origin, most of them were believed to be of toxic nature. Among these are placental infarcts, autointoxication, uremia, pyelonephritis, and maternal sensitization to total proteins.

The i ncidence of PIH among pregnant women is very high (8%), costing hundreds and thousands of lives of both mothers and fetus around the world. This commonly affects first-time pregnancies due to the presence of functioning tropoblasts (develops after the 20 th week of gestation and stays evident until after 48 hours after delivery. Age is also an important indicator in the development of PIH. Too early, as in teenage pregnancies and old primigravidas (first-time pregnancy) as in over 35 years of age put a woman higher chances of having pregnancy-induced hypertension . 

PATHOPHYSIOLOGY

SIGNS AND SYMPTOMS

The signs and symptoms of the type of PIH present in a pregnant woman are based on the presentation of evident clinical manifestations. These are shown in the table below:

COMPLICATIONS

Based on the severity of the PIH present to a person or the extent of damage left/occurred, a list of possible complications can be drawn.

  • Abruption placenta
  • Disseminated intravascular coagulation (DIC)
  • Prematurity
  • Intrauterine growth retardation (IUGR)
  • HELLP syndrome
  • Maternal and/or fetal death  

The changes of the mother and/or fetus to survive after an episode of convulsion or until delivery depends on the threshold on the effects of PIH and its complications. This can be:

  • Good— if the symptoms are mild or those that are with mild pre-eclampsia and is responding well to the treatment regimen
  •   Poor— if there are multiple and long episodes of convulsions that are associated or lead to the development of persistent coma, hyperthermia, cyanosis, tachycardia, and liver damage.
  • Congestive heart failure (CHF)
  • Pulmonary edema
  • Cerebral hemorrhage
  • Renal failure

DIAGNOSTIC EVALUATIONS

            Diagnostic evaluations are performed after episodes of convulsions or after the client has been rushed to a health care facility. These are routinely done to assess the damages and will serve as the basis for the plan of treatment.

  • 24-hour urine-protein— health problem through protein determination from the involvement of the renal system.
  • Serum BUN and creatinine— to evaluate renal functioning.
  • Ophthalmic examination— to assess spasm, papilledema, retinal edema/detachment, and/or hemorrhages.
  • Ultrasonography with stress and non- stress test— to evaluate fetal well-being after.
  • Stress test —fetalheart tone (FHT) and fetal activity are electronically monitored after oxytocin induction which causes uterine contraction.
  • Non-stress test —fetal heart tone (FHT) and fetal activity are electronically monitored during fetal activity (no oxytocin induction).  

NURSING DIAGNOSES

  • Fluid volume excess related to altered blood osmolarity and sodium/water retention.
  • Altered nutrition, less than body requirements related to loss through damaged renal membrane.
  • Altered tissue perfusion related to increased peripheral resistance and vasospasm in renal and cardiovascular system.
  • Altered urinary elimination related to hypovolemia.
  • Sensory/perceptual alterations: visual related to cerebral edema and decreased oxygenation of the brain.
  • Diversional activity deficit related to decreased time for rest and sleep from stimulating environment.
  • Risk for injury related to seizure episodes.
  • Anxiety-related to fear of the unknown.    

            The overall goal of management in pregnancy-induced hypertension is directed towards the control of hypertension and the correction of developed health problems that might leadto other serious complications. Among the specially-designed treatment course for PIH are the following:

  • Use of antihypertensive drugs (hydralazine-drug of choice)
  • Diet-high protein, high calories
  •   Magnesium sulphate (MgSO4) treatment
  • Diazepam and amobarbital sodium (if convulsions don’t respond to MgSO4)
  • Beta-adrenergic blockers (used for acute hypertension)
  • Delivery (if all treatment regimen don’t work)

NURSING MANAGEMENT

A.   Assessment

  •   Monitor blood pressure in sitting or side-lying position.
  • Monitor fetal heart tone (FHT) and fetal heart rate (FHR).
  • Check for deep tendon reflexes (DTR) and clonus.
  •   Monitor intake and output (I&O) and proteinuria.
  • Monitor daily weight and edema.
  • Assess for signs of labor (possibility of abruption placenta).
  • Assess for emotional status.

B.  Interventions

1.  Fluid balance

  • Maintain patent and regulated IVF
  • Strict I&O monitoring
  • Monitor hematocrit level
  • Vital signs monitoring every hour
  • Assess breath sounds for signs of pulmonary edema

  2.  Tissue perfusion

  •  Position on left-lateral position
  • Monitor fetal activity (stress and fetal activity)

3.   Preventing injury

  • Monitor cerebral signs and symptoms (headache, visual disturbances, and dizziness)
  • Lie on left-lateral position if cerebral symptoms are present
  • Secure padded side rails
  • Keep oxygen suction set, tongue blade, and emergency medications (diazepam and magnesium sulphate) at all times
  • Never leave an unstable patient

4.   Anxiety

 Discuss the health condition and planned treatment

  • PIH is not lifetime
  • PIH is only for the first pregnancy
  • All medications and its maternal and fetal effects

Allow to ask questions and answer it truthfully

Provide emotional support to the client and family

C.   Educative

  • Reinforce the importance of rest and sleep
  • Encourage family cooperation with the treatment course
  • Discuss the laboratory procedures and alternative managements
  • Include medical team, client, and significant others in the discussion
  • Be realistic in discussing the possibilities of premature delivery  
  • No sign of pulmonary edema
  • Adequate urine output
  • No episode of seizure
  • Stable and normal heart rate

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  • Open access
  • Published: 02 December 2021

Pregnant women’s experiences with the management of hypertensive disorders of pregnancy: a qualitative study

  • Amyna Helou 1 ,
  • Kay Stewart 1 ,
  • Kath Ryan 2 &
  • Johnson George 1  

BMC Health Services Research volume  21 , Article number:  1292 ( 2021 ) Cite this article

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Hypertensive disorders are a leading cause of mortality and morbidity during pregnancy. Despite multiple national and international clinical guidelines and a plethora of research in the field of optimising management, there has been limited research describing the perspectives and experiences of pregnant women with the management of hypertensive disorders of pregnancy (HDP). Understanding these perceptions and experiences is imperative to the optimisation of HDP management.

A qualitative study involving face-to-face, in-depth interviews were undertaken with 27 pregnant women diagnosed with and being treated for HDP to explore their perspectives of and experiences with clinical management. Written consent was obtained individually from each participant, and the interviews ranged from 16 to 54 min. Inductive codes were generated systematically for the entire data set. Line-by-line analysis was then performed and nodes were created within NVivo, a qualitative data management software. Data collection was continued until thematic saturation was reached. Thematic analysis was employed to interpret the data.

Three major descriptive themes were discerned regarding the women’s perspectives on and experiences with the management of HDP: attitudes towards monitoring of HDP, attitudes and perceptions towards development and management of complications, and perceptions of pregnant women with chronic hypertension. Trust in the hospital system, positive attitudes towards close blood pressure monitoring as well as self-monitoring of blood pressure, and a realistic approach to emergency antenatal hospital admissions contributed to a positive attitude towards monitoring of HDP. Women with prior experiences of HDP complications, including pre-eclampsia, were more confident in their clinical management and knew what to expect. Those without prior experience were often in shock when they developed pre-eclampsia. Some women with chronic hypertension displayed limited understanding of the potential risks that they may experience during pregnancy and thus lacked comprehension of the seriousness of the condition.

Conclusions

The clinical management experiences of pregnant women with HDP were varied. Many women did not feel that they were well informed of management decisions and had a desire to be more informed and involved in decision-making. Clear, concise information about various facets of HDP management including blood pressure monitoring, prescription of the appropriate antihypertensive agent, and planning for potential early delivery are required .

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Introduction

Hypertensive disorders of pregnancy (HDP) affect around 10% of pregnancies in Australia and around the world [ 1 ]. Combined, they are the second largest cause of maternal death, after haemorrhage, in the developed world [ 1 ].

In Australia, the public health system provides maternity care from pre-conception to postpartum. The main health professionals who care for the pregnant women are obstetricians, midwives, general practitioners (GP) and obstetric physicians [ 1 ]. The GP has an important role in pre-conception counselling, especially with women who have chronic diseases such as hypertension or asthma. It is also the responsibility of the GP to confirm the pregnancy and refer the woman to the relevant maternal hospital service.

Initially, the choice of model of care is given to the woman. The Midwifery Group Practice model [ 1 ] allows for one-to-one maternal care, often with the same midwife throughout the term of pregnancy, which is a suitable option for women without complications. Pregnant women with complications such as chronic hypertension or a previous pregnancy complicated by hypertensive disorders of pregnancy (HDP), however, need to be cared for by an obstetrician, who can monitor the progress of the pregnancy, blood pressure (BP), signs of pre-eclampsia, and fetal growth. The obstetric physician is usually involved in prescribing and monitoring antihypertensive medication and BP control. Pregnant women who have had pre-eclampsia previously or who have chronic hypertension are at risk of developing pre-eclampsia. Timely administration of low-dose (81-100 mg) aspirin before 16 weeks gestation has been found to reduce risk of pre-eclampsia [ 2 ].

Monitoring of BP occurs at each antenatal visit. If her BP is elevated, the woman may be referred to a day assessment unit for 4-h assessment of BP, which involves taking BP readings every half an hour for 4 h to observe the pattern of the BP and decide whether a diagnosis of HDP and/or prescription of an antihypertensive medication is warranted. In addition, test for urinary protein, full blood examination, renal function tests and fetal monitoring are performed [ 3 ]. This 4-h assessment is seen as a favourable alternative to overnight inpatient stays, both in terms of patient satisfaction and public health economics [ 3 ].

The timing of delivery in women with HDP is dependent on many maternal and fetal factors, including inability to stabilise BP, deteriorating liver and/or renal function, placental abruption, and severe fetal growth restriction [ 4 ]. Fetal morbidity and mortality are linked to the gestational age at delivery [ 4 ], so there is always a desire to prolong the pregnancy as close as possible to term (37 weeks) in the absence of an emergency. HYPITAT was a multicentre, open-label randomised controlled trial investigating induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks’ gestation [ 5 ]. The study reported a reduction in the incidence of severe hypertension as result of induction of labour at 36 weeks gestation. No significant clinical differences were found in outcomes such as thromboembolism, eclampsia or placental abruption [ 5 ]. This study was followed by HYPITAT-II, which found that delivery should be deferred until 37 weeks as opposed to 36 weeks, unless maternal deterioration supervenes [ 6 ].

Despite multiple clinical guidelines [ 4 , 7 , 8 ] and a plethora of research in the field of optimising HDP management, there have been limited published studies describing the experiences of pregnant women with the management of HDP, as distinct from medication treatment.

A survey of women with pre-eclampsia or their partners, friends or relatives found that many had no knowledge of pre-eclampsia prior to diagnosis and once diagnosed, did not appreciate how serious or life threatening it was [ 9 ]. Women wanted access to information about pre-eclampsia and their experience contributed substantial anxiety towards future pregnancies. Partners/friends/relatives also had no prior understanding of pre-eclampsia and expressed fear for the woman and/or her baby [ 9 ]. A qualitative study of pregnant Moroccan women in the Netherlands or Morocco found that knowledge of symptoms related to hypertensive disorders of pregnancy was limited or absent [ 10 ]. The limited knowledge of hypertension-related symptoms and complications was based on their own experiences or on those of some family members or stories from their social network or internet, with little or no information on symptoms from their midwives or obstetricians [ 10 ]. The experiences, perceptions and behaviours of pregnant women with regard to the management of HDP during pregnancy remain largely unexplored. Understanding these perceptions and experiences is imperative to the optimisation of HDP management.

To explore pregnant women’s perspectives of and experiences with clinical management of HDP.

Study design

A qualitative study using in-depth interviews was conducted, with pregnant women in their second or third trimester, recruited from antenatal clinics in two large tertiary hospitals in Melbourne, Australia.

Participants were sourced via a larger mixed-methods study, which included 100 pregnant women with HDP. Eligible participants were identified by one researcher (AH), who reviewed the medical records of pregnant women attending antenatal clinics, and then approached them individually. Participants were provided with written information for the larger study and on receipt of written informed consent, a questionnaire was given for self-completion. At the end of the questionnaire, participants were asked to indicate their interest in undertaking an interview. Of the 98 women who responded to the questionnaire, 65 expressed interest in being interviewed. Combined convenience and purposive sampling was conducted among these 65 women to seek a breadth of views. All of the women who were invited accepted to participate in an interview. Informed written consent was obtained prior to each interview, which included permission to audio record the conversation and to use quotations when anonymously reporting and publishing the results.

Study sample

Face-to-face, qualitative in-depth interviews were conducted with 27 pregnant women who were diagnosed with HDP and had a prescription for an antihypertensive medication, in either the second or third trimester of pregnancy, recruited from the antenatal outpatient clinics of two large tertiary maternity hospitals in Melbourne, Australia. Together, these hospitals provide antenatal care to approximately 13,000 women annually. They were identified using hospital records and approached during subsequent clinic visits. Participation was voluntary and involved informed consent.

The study sample size was determined based on theme saturation during analysis and was not predetermined. Recruitment ceased when no new information was forthcoming from the last three interviews, with regard to replication of data relating to attitudes towards HDP monitoring, perceptions of the development and management of complications (including early delivery) and perceptions of the women who had chronic hypertension.

Data collection

Interviews were conducted face to face by a single researcher (AH) a female Pharmacist (who was a PhD candidate at the time) after receiving training in in-depth interviewing prior to the commencement of the study using an interview guide developed based on the literature [ 11 , 12 ] and was agreed upon by the authors (Table  1 ). Open-ended questions, such as “Tell me about …? ”, followed by appropriate prompts, such as “How did that make you feel?” or “Can you explain that in more detail?” were used to guide the interview and encourage the interviewee to speak freely and in-depth about their experiences and thoughts. As the interviewer had met the participants during the larger study, some rapport had been established prior to the interview. The interviewer did not disclose their healthcare background to participants to avoid requests for health advice during the interviews. Interviews on average lasted 35 min (range 16 to 54 min) and were conducted in a private room near the antenatal clinics. No repeat interviews were performed.

Socio-demographic and self-reported health information was collected from participants through the questionnaire. Health information was verified, with consent, through medical records.

All interviews were audio-recorded, transcribed verbatim and de-identified. Interviews continued until data saturation was reached, deemed to be the point after which no new information for analysis was forthcoming [ 13 ]. The transcripts were not returned to the participants for comments or correction.

Data analysis

Data analysis occurred concurrently with the interviews. Initial coding was completed by AH using the qualitative data management software QSR NVivo 10 (QSR International) [ 14 ]. Inductive codes were generated systematically for the entire data set. Line-by-line analysis was then performed and nodes were created within NVivo. To ensure reliability, a random selection of 20% of the transcripts were coded independently by another member of the research team (KS). KS and KR read all the transcripts and any differences were discussed among all three to reach consensus. The researchers were all pharmacists; KS and KR had extensive experience in conducting qualitative research. Transcripts were reread by AH and KS to ensure that coding was accurate and all relevant data were included.

Thematic analysis was employed [ 15 ]. This was done across all HDP subtypes and severities to obtain a wide range of views. AH read and reread the codes, collapsed them into potential themes, compared the developing themes with the intact transcripts and cross referenced to HDP subtypes. When a pattern was seen within a certain subtype, coding was grouped specifically for that subgroup. Codes were arranged into potential themes. Themes were reviewed, refined and prepared into a final set with KS; sub-themes were identified within this process.

Participants

Of the 98 women who responded to the questionnaire, 65 expressed interest in being interviewed. A combination of convenience and purposive sampling was conducted among these women to seek a wide breadth of views. All participants had a diagnosis of HDP and were prescribed antihypertensive medication. Interviews occurred during pregnancy except for one, which happened 1 day postpartum. All participants were aged 18 years or over and were fluent in English. Twenty-seven women were interviewed to reach data saturation. Their demographics, clinical and obstetric characteristics are shown in Table  2 . Family members were present for some interviews but none of them participated in the interview or made comments. Field notes were taken by the interviewer during the interviews. No participants dropped out of the study or refused participation.

Eight participants were primigravidae, the remainder were multigravidae, including six who had previous miscarriages. One participant had an assisted pregnancy (in vitro fertilisation). Twelve were prescribed aspirin for the prevention of pre-eclampsia. Participants ranged in age from 26 to 42 years. The annotations at the end of each quote give a description of the participant’s age, parity, gestational trimester and subtype of HDP at the time of the interview. The participants did not provide feedback on the findings.

Interview themes

Three major descriptive themes were discerned regarding the women’s experiences with the management of HDP:

attitudes towards monitoring of hypertensive disorders of pregnancy;

attitudes and perceptions towards development and management of complications; and

perceptions of pregnant women with chronic hypertension.

Theme 1: Attitudes towards monitoring of hypertensive disorders of pregnancy.

Most women had general trust in the hospital system. Some felt extra confidence knowing that they were being managed at a maternity hospital:

“Hospital is for saving lives of people...as soon as I see the hospital I know that I am in safe hands.” (#14, 40 years, 2nd pregnancy, second trimester, severe pre-eclampsia).
“I felt very comfortable here...it seems like they are well prepared for these things...I was in the section of the hospital where all women were in the same [hypertension] situation.” (#9, 30 years, 1st pregnancy, second trimester, chronic hypertension).

One woman expressed some distrust in general hospitals, which she perceived as not managing her BP well:

“My own GP at that time increased it [methyldopa] to six a day … the hospital … increased to 10 a day … but I couldn’t lift my head up … so I ended up coming to the women’s hospital to Emergency, because I felt like no one’s helping me.” (# 71, 37 years, 3rd pregnancy, third trimester, severe pre-eclampsia superimposed on chronic hypertension).

Self-monitoring of BP was often recommended to women treated with antihypertensives. For some, it gave reassurance, but for others it was a source of confusion, with different messages coming from various members of the treating team:

“I take up to eight [methyldopa tablets] a day...I take two and then I’ll see what my readings are...at home, myself...I also do it if I have any other symptoms.....” (# 71, 37 years old, 3rd pregnancy, third trimester, severe pre-eclampsia superimposed on chronic hypertension).
“One of the physicians I saw told me to do it three times a day … three times in a row and then she said take the average of the second two readings each time...Then I told the obstetrician my readings and she said the machine that I had at home is under-measuring...but...the physician, he was quite interested...he wanted to see my readings because he likes to compare his machine to home machines.” (#53, 40 years, 6th pregnancy, third trimester, secondary chronic hypertension).

Some women had milder HDP in previous pregnancies, which gave them a sense that the monitoring and management was overstated. Others with more severe cases and their prior experience brought back memories initiating action to make plans:

“With [child 1] it was really bad during pregnancy. With [child 2] it was bad just in the last couple of weeks and straight afterwards...[child 3] was bad, but not really bad enough. They just called it hypertension, pregnancy induced hypertension and they just left it at that. They didn’t make a big song and dance about it...They made a big song and dance last time [child 4] and then this time [they said] ‘You’re going for your monitoring’...come back a week later...’You’re going for your monitoring’, couple of hours later – ‘You’re being admitted’...Then a couple of hours later...’You’re starting on medicine’.” (#6, 28 years, 4th pregnancy, 1 day postpartum, gestational hypertension).
“Last Wednesday when they [found] blood pressure’s up … it just brought back memories from last time because same thing. I just went in for an appointment and I never came home...Ten days later I came home with a baby. So I think those aspects freak me out a bit because it’s like ‘Oh, it’s happening again’ … every appointment...even this appointment, we’ve got contingency plans, just in case.” (#74, 36 years, 2nd pregnancy, third trimester, chronic hypertension).

Some women wondered about why they were not told their BP readings unless they asked:

“I find it funny that when they take your blood pressure they don’t tell it to you. I always have to ask, always, no matter who it is, midwife, physician, obstetrician. They take it and they walk away. It’s my body but they don’t tell me.” (#53, 40 years, 6th pregnancy, third trimester, secondary chronic hypertension).

Close monitoring was perceived as frustrating, but also as part of the life adjustments that come with having a baby. Some women considered spending four hours in the day assessment centre for monitoring their BP better than being an inpatient and staying overnight, whilst others saw it as an annoyance:

“I am happy to come back every day as long as I don’t have to spend overnight here. I am happy to be here for 12 hours a day, but I just can’t be away from my children at night time.” (#29, 26 years, 3rd pregnancy, second trimester, secondary chronic hypertension).
“They just monitor me at that perinatal care...you just sit here four hours a day...it’s shocking...worse than taking the tablet.” (#90, 35 years, 7th pregnancy, third trimester, chronic hypertension).
“The only thing that was slightly frustrating was [that] four hours is a long time to sit around, but again, you’re having a baby so you’ve got to make a few adjustments to your life.” (#99, 34 years, 1st pregnancy, third trimester, pre-eclampsia).

Some of the women required a short inpatient stay to stabilise their BP and avert an emergency premature delivery. For many, it was an emotional experience filled with apprehension and uncertainty about the future:

“It was very emotional, very scary, and at the same time still trying to stay strong. So that when my husband and my kids came in, I was like ‘I’ve just got a little bit high blood pressure, everything’s alright’...I didn’t know that a possible side effect of having the blood pressure is that they may have to deliver the baby [early].” (#32, 42 years, 3rd pregnancy, third trimester, severe early onset pre-eclampsia).
“B.P. at first was around 160...she came back 15 minutes – 170, another 15 minutes 180, within 10 minutes 190...I got nervous … After 160 they gave me ...labetalol...but [the BP] did not go down...There were other tablets they gave to me but [the BP still] didn’t go down...All the doctors came up...surrounded with those with scrub suits, I panic...blood pressure...went to 210..they were panicked...one just looked at me and said “AAAH”. I cried...of course you feel anxious, you feel sad...worried... what’s going on with me? I cried and cried. It was just like a movie, they push my bed out from the room and sent me quickly down to the birthing suite [in case delivery was imminent].” (#14, 40 years, 2nd pregnancy, second trimester, severe pre-eclampsia).

Theme 2: Attitudes and perceptions towards development and management of complications.

For many women, the diagnosis of pre-eclampsia came as a shock. Those with prior experience knew what to expect and were hesitant to cease antihypertensive treatment even if their BP was low. One woman without prior experience self-educated about pre-eclampsia, became concerned about the symptoms and developed anxiety about developing it:

“It was a shock and it was a bit scary...I thought ‘I’ve heard of pre-eclampsia but I don’t really know what it is’...but all the staff, they explained everything quite well... [I could see] how they were being very concerned about it, so that was making me realise this isn’t just a small thing, this is obviously a serious situation.” (#32, 42 years, 3rd pregnancy, third trimester, severe early onset pre-eclampsia).
“I didn’t want to stop the medication altogether, only because I just didn’t want to go through the path of having the high blood pressure affect the baby [intra-uterine growth restriction].” (#8, 36 years, 2nd pregnancy, third trimester, chronic hypertension).
“I was reading that if you do develop pre-eclampsia... it is a risk for the baby and the mother as well. Upon reading all that information...I became a bit paranoid, swollen foot, swollen hands, they’re part of the symptoms, headaches, generally not feeling well...I became quite paranoid looking at my symptoms and [thinking] have I got this, have I not got this? But the doctors actually did say that I have got borderline pre-eclampsia, so they were waiting to see if I was going to develop it. However, they haven’t been able to reassure me that I’m not going to develop it and...that was quite scary for me.” (# 24, 35 years, 1st pregnancy, third trimester, chronic hypertension diagnosed during pregnancy).

Some women understood that low-dose aspirin was being used for prevention of pre-eclampsia, whereas others did not always perceive it as being effective for this purpose. Many women thought that aspirin helped with controlling the BP rather than for prevention of pre-eclampsia:

“I started on aspirin throughout the pregnancy … just to...prevent mild pre-eclampsia happening again.” (#64, 30 years, 3rd pregnancy, third trimester, chronic hypertension).
“Obstetrician put me on one aspirin a day which is supposed to help control blood pressure. So perhaps that’s also why my blood pressure is being well controlled.” (#21, 35 years, 1st pregnancy, second trimester, chronic hypertension).

Most women had a general understanding that the only way to stop the direct effects of pre-eclampsia was to deliver the baby for the safety of both mother and child. The level of comfort with such a decision varied depending on the gestational stage of diagnosis of pre-eclampsia:

“I was really disappointed and very worried about the effect it [pre-eclampsia] would have on the baby [at 21 weeks] and whether or not I would be able to carry the baby to a safe week. I just thought...if something had happened and I was forced, like accidentally went into labour too early or something like that, the baby’s chances of survival would be very low and I was really upset.” (#21, 35 years, 1st pregnancy, second trimester, chronic hypertension).
“All I know is that you just need to get the baby out...I mean plenty of women and plenty of babies survive it...but you need to detect it pretty quickly before it turns into the full...is it eclampsia?” (#41, 34 years, 1st pregnancy, third trimester, chronic hypertension).

Although many women understood that they would not continue to full-term, their perceptions and fears about the potential for a premature delivery were related to their week of gestation, concern about the welfare of the baby, and fear of separation after the birth:

“I know from my reading that 24 weeks, it’s still not ideal obviously, but if you had the baby at 24 weeks that the chance of survival was higher. I think it was 43% chance of survival from this...prior to that it was like 16% chance of survival...My sister-in–law, who is a midwife, had said...they consider 26 weeks more viable. So after that it was like, right (a) to get to 24, (b) get to 26.”. (#21, 35 years, 1st pregnancy, second trimester, chronic hypertension).
“I am just worried about my baby [having] to be delivered earlier because you see the consequences...you see things happen in the future...they are still very weak...no sucking reflex yet, the lungs are not fully developed, so many things not developed...she may live but maybe there are some disabilities...I am just hoping that I will reach even up to 30 weeks or 32 weeks. That would make me feel better.” (#14, 40 years, 2nd pregnancy, second trimester, severe pre-eclampsia).
“I was 28 weeks [when I developed severe pre-eclampsia]...they gave me steroid injections to increase the lung capacity of the baby...One of the doctors came from the NICU with a leaflet about possibly having a premature baby...that was very upsetting...and to think of having the baby...then me going home with the baby staying here is just a very scary thought.”(#32, 42 years, 3rd pregnancy, third trimester, severe early onset pre-eclampsia).

Intervention with the delivery process was a likely reality for many women who had a prospect of early delivery. Some women were apprehensive about the prospect of induction of labour or caesarean section but understood that it was for their benefit and that of their child. Others were hesitant to allow for intervention unless the risks were made clear:

“So a little bit scary, but in a way I want it to, because I’m starting to feel the uncomfortable risk that’s associated with pregnancy in this condition. Knowing that she’s at full term now at 37 weeks and she’s fine and healthy, I don’t want to develop pre-eclampsia if I can help it.” (# 24, 35 years, 1st pregnancy, third trimester, chronic hypertension diagnosed during pregnancy).
“I’m trying to push it off because I don’t want to do it. I like to have the baby when the baby’s ready, not when they tell me to. But if they tell me to because it’s really dangerous for me then I’ll listen to them obviously ….” (#53, 40 years, 6th pregnancy, third trimester, secondary chronic hypertension).

Concerns about lack of information sharing by health professionals led some women to feel that they were left out of the planning for potential intervention in the delivery, whilst others voiced concern about having low-dose aspirin in the context of a possible emergency caesarean section:

“I even asked her last time actually because she said...I’m happy with the baby’s growth, but the blood pressure’s going up so … she said ‘I’m formulating a plan in my mind’ but she doesn’t like to disclose it. I don’t know why. It’s about me; I don’t know why she just doesn’t tell me.” (#53, 40 years, 6th pregnancy, third trimester, secondary chronic hypertension).
“I also thought...what if I have an emergency caesarean tomorrow and I haven’t gotten off the aspirin? Is it going to cause me issues?” (#29, 26 years, 3rd pregnancy, second trimester, secondary chronic hypertension).

Theme 3: Perceptions of pregnant women with chronic hypertension.

Many women with chronic hypertension were already on antihypertensive medication not deemed safe during pregnancy when they found out they were pregnant. For some, it was changed to a safer alternative as soon as possible, whilst for others, the decision to change the medication was delayed and the patient’s assessment of potential risks was downplayed:

“I was on medication [telmisartan]...then when I had the kidney scan and I found out [that I was pregnant], my G.P. said ‘You’ve got to stop taking that medication because it’s not safe...so then she gave me another one to take.” (#2, 30 years, 1st pregnancy, third trimester, secondary chronic hypertension).
“The first time I found out I was pregnant I went to a GP...I told the GP that I’m taking atenolol, and then she told me that...atenolol is not recommended for pregnancy... so I asked....What medication do you think that I should take?’...she said she doesn’t dare to prescribe me any medicine because she knows she is going to refer me to a hospital.” (#59, 34 years, 1st pregnancy, second trimester, chronic hypertension).

Other women had their antihypertensive changed during the pre-pregnancy planning stage:

“[To be safe during pregnancy] I would just have to change my medications. The medication I was on I couldn’t be on while being pregnant. So when we decided to try for our first child, I went on the Aldomet and oxprenolol and that’s what I pretty much stayed on because we always wanted a second child.” (#1, 39 years, 2nd pregnancy, third trimester, secondary chronic hypertension).

Some women with chronic hypertension had concerns about lack of information sharing by health professionals and felt that they were not well informed of the potential risks that their hypertension may have on the pregnancy. Some mentioned that they may have ‘taken it more seriously’ if they had known about the risk of premature delivery associated with uncontrolled hypertension, whilst others had some limited awareness of pre-eclampsia:

“When they told me I had protein in my urine, I was a bit scared because I don’t know if it’s related to my BP.” (#4, 33 years, 1st pregnancy, third trimester, chronic hypertension).

One woman was very anxious about her diagnosis of severe, early-onset pre-eclampsia so she did some ‘self-research’. Unfortunately, she misinterpreted the information and caused herself extra unwarranted fear:

“I read on [US website found on Google] and found that 80% die after/during birth that have pre-eclampsia. That was really scary.” (#71, 37 years, 2nd pregnancy, third trimester, severe pre-eclampsia superimposed on chronic hypertension).

The information on the US Preeclampsia Foundation website actually states that “Nearly 80% of women who die from pre-eclampsia die post-partum” [ 16 ].

For some women with chronic hypertension, lack of knowledge of the seriousness of the condition resulted in lack of comprehension of the importance of BP monitoring and treatment:

“I think it was about 140 over 110 or something like that … which is pretty normal for me but they think it’s high … I feel alright. It’s all good.” (#90, 35 years, 7th pregnancy, third trimester, chronic hypertension).
“I really tried for weeks not to go on [the antihypertensive], but then when she said that maybe you could have a stroke, I got a bit scared, a lot scared … I got really worried because then they said … you could have problems, the baby could die. And I got really upset when she said the baby could not get enough oxygen. I just felt, oh just have whatever it is.” (#22, 37 years, 3rd pregnancy, third trimester, chronic hypertension).

Most women who had chronic hypertension were under a model of care involving both an obstetrician and a physician. One was triaged to midwife-only care, despite having a diagnosis of chronic hypertension and being prescribed an antihypertensive medication. This then caused a delay in the change of the antihypertensive to a safer alternative:

“Actually, I asked the midwife whether it [atenolol] is safe or not [at 18 weeks gestation]...and then she said that...it should be okay, but to be safe discuss with the physician. And so, because she said it should be okay, I presumed that ‘Oh that is okay’ ... but then the physician said ‘No, it’s better not to...so from now onwards you have to take this medicine [oxprenolol]’.” (#59, 34 years, 1st pregnancy, second trimester, chronic hypertension).

Many women had their first antenatal appointment at the hospital between 16 and 20 weeks gestation. Some women, especially those with chronic hypertension, had concerns about the timing of this appointment:

“It takes a long time now for women to get their first appointment through the hospital. It wasn’t like that, I think, about 10 years ago, must’ve changed by now … Now you have to wait ‘til you’re about 18, 20 weeks before you get your first actual appointment...and if you’ve got other health issues, things can go wrong, which it did with me.” (#71, 37 years, 2nd pregnancy, third trimester, severe pre-eclampsia superimposed on chronic hypertension).

Some women did not know that they had high BP before pregnancy. This may have been because they did not get regular check-ups with the GP or that their BP was not routinely checked at regular GP visits:

“I think if I had never gotten pregnant, I definitely would not have had [high BP], would not have to be on medication … because I wouldn’t be under the strain that I am. And also I wouldn’t be in with the doctor. I don’t think I would’ve gone to the doctor and said put me on medication … because I didn’t, want anything to change. But my lifestyle is changing now so I don’t have a choice.” (#18, 35 years, 2nd pregnancy, second trimester, chronic hypertension).
“It [BP] was quite normal before the pregnancy, so obviously it’s pregnancy-related according to the doctors [despite having been diagnosed at 7 weeks].” (#24, 35 years, 1st pregnancy, third trimester, chronic hypertension diagnosed during pregnancy).

Many women had developed chronic hypertension after a previous pregnancy that involved either gestational hypertension or pre-eclampsia. Some of them had routine follow-up for their hypertension postpartum and understood that it was now chronic hypertension, whilst others did not:

“Once I’d had the baby they changed my medication to the perindopril...I was then checking my BP at home...the readings were fine...when they did get too high, I’d go back to my local GP who would then once again adjust the dosage accordingly...I have been told by my local GP that generally once you’re on a blood pressure medication, you’re on it for life, whether it’s a minimal dosage or, depending on what the readings are, what they need to give...I’m happy to stay on that.” (#8, 36 years, 2nd pregnancy, third trimester, chronic hypertension).
“I got increased blood pressure at the end [of the previous pregnancy] and they put me in perinatal care, but then afterwards it was okay....I honestly just didn’t go to the doctor, and I haven’t gone to the doctor since I fell pregnant with this one.” (#90, 35 years, 7th pregnancy, third trimester, chronic hypertension).

One woman described having been prescribed an antihypertensive during her previous pregnancy and never told to stop it, so she continued with no formal review of her hypertension until the current pregnancy:

“They never told me to stop taking the tablet [labetalol] after I had him [first child] so I just kept continuing with it ... I saw the physician [during this current pregnancy] and he just said just keep taking it...he actually questioned ‘Did they ask you to stop it?...I said no one spoke to me about anything...I was here for a week after I had him [first child]...no one ever discussed it.” (#58, 38 years, 2nd pregnancy, third trimester, chronic hypertension).

Trust in the hospital system, positive attitudes towards close BP monitoring as well as self-monitoring of BP (SMBP) and a realistic approach to emergency antenatal hospital admissions contributed to a positive attitude towards monitoring of HDP. Most of the women in our study had a general trust in the healthcare system. Distrust surfaced when health services outside the women’s hospital were not seen as able to control hypertension early in the pregnancy, triggering patient-initiated referral to the women’s hospital. Trust of healthcare systems in western countries is generally declining [ 17 ]. It is, however, important to note that pregnant women with HDP are considered to be in a high-risk pregnancy and are thus more vulnerable than the general population. Therein lies dependence on the hospital system, especially in urgent situations such as needing to lower BP or planning for an early delivery, similar to the dependence reported in patients with coronary heart disease [ 18 ].

Anecdotally, it is common for healthcare professionals to mention that the BP reading is ‘good’ or ‘too high’ without telling the patient the systolic/diastolic numbers. An important factor relating to patient evaluation of care is their involvement in decision-making [ 19 ]. Most of the women in our study were not involved in decision-making, leaving some to wonder why this was so. This suggests that pregnant women with HDP would like to be better informed of their situation and be part of the decision-making process when deemed appropriate. This is consistent with the women’s views from the pilot of the CHIPS study who enjoyed being heavily involved in their BP management [ 20 ]. One way to have women more involved in their BP management is to encourage SMBP. SMBP in the general population has been shown to reduce BP [ 21 ] and improve adherence to antihypertensive medication [ 22 ]. In our study, SMBP was often recommended to women who were prescribed antihypertensive medications. This was taken up well by most, similar to the CHIPS pilot study [ 20 ]. SMBP during pregnancy has also been shown to be reassuring and not anxiety provoking [ 23 ] which was seen in our study. A recent survey of 5555 pregnant women from antenatal clinics in 16 hospitals in England, found that nearly half of the 389 hypertensive women reported SMBP, and that the majority of them (79%) shared their BP readings with their treating doctor [ 24 ]. Such partnership has been shown to improve patient adherence in the general population [ 25 ]. There is however an assumption that because these women are in a high-risk pregnancy, the healthcare professionals (HCP) tend to take over and do not acknowledge that the women are quite competent and that with the correct information can be involved in SMBP in collaboration with the HCPs. It is thus important to have a good doctor-patient relationship to reduce confusion, instil confidence in SMBP and complete the circle of care.

Those with prior experience with HDP and monitoring had varied views, often depending on the severity of disease in the previous pregnancy (ies). Good communication about how HDP can vary from one pregnancy to another, being either worse or better, may assist in reducing the cynicism of some and reassure others. Similarly, those who had prior experience with pre-eclampsia were a lot more confident in their management and knew what to expect. Those who did not have prior experience were often in shock and were at times anxious about the diagnosis, a finding similar to another study relating to the understanding of pre-eclampsia [ 26 ]. Moreover, the use of low-dose aspirin to prevent pre-eclampsia was only partially understood by women in our study. This indication should be communicated clearly to women who are at high risk of developing pre-eclampsia. The plan for the cessation of aspirin before delivery should also be communicated clearly to reduce any anxiety that may be present, especially in terms of a potential emergency delivery.

At times, antenatal inpatient admission was required to stabilise BP and closely monitor both the mother and baby. This was a particularly apprehensive time, especially for women who had not experienced HDP during a previous pregnancy. It is important to have good, clear communication with women about the need for close monitoring, affirmation concerning their status as worthy of hospital care, provision of consistent information, inclusion in decision-making and good social support [ 27 ]. A possible alternative to inpatient admission can be pregnancy day assessment monitoring. Despite limited research into this model of care, pregnant women have been found to prefer a four-hour stay rather be admitted to hospital for one or more nights, if the situation is deemed safe to do so [ 3 ]. This is consistent with our findings. Once again, clear consistent information regarding the need for this type of monitoring should be given to women who require it. Recent advancements in the integration of telemedicine into antenatal care [ 28 ] have encouraged early research into the feasibility of incorporating this for women with HDP to reduce the burden of multiple antenatal hospital visits [ 29 ]. The unpredictable course of worsening BP and the development of pre-eclampsia pose specific challenges to this monitoring and would require a holistic approach. A recent single centre study in the UK [ 29 ] developed and trialled an innovative SMBP intervention including a downloadable mobile app in for women with HDP to monitor for signs of pre-eclampsia or worsening hypertension. Although this study showed positive acceptance and compliance from the women, further research is required to meet the standard of care required for them [ 29 ].

In general, most women desire to labour spontaneously and have a natural birth [ 30 ]. When the reality that the only way to stop the direct effects of pre-eclampsia is to deliver the baby at any given gestational week is revealed to some women, it is received with disappointment. Good communication by the treating doctor about the intention to preserve the pregnancy for as close as possible to term is required. Likewise, sound communication about the need for a premature delivery should be communicated clearly. Moreover, it has been shown that pregnant women who require induction of labour or caesarean section often feel left out of the decision-making process [ 30 ]. An Australian study of women’s experiences of decision-making and attitudes in relation to induction of labour, reported a clear need for women to be provided with more information and agency when making decisions about their timing of birth, particularly when there are multiple reasonable treatment options [ 30 ]. Furthermore, emergency caesarean sections have been found to negatively contribute to several psychosocial outcomes for women, in particular post-traumatic stress [ 31 ]. There is, thus, a need for careful consideration and counselling for women after an emergency caesarean delivery. This can involve the members of the antenatal treating team but also counsellors or psychologists. Moreover, counselling of pregnant women who are at risk of emergency caesarean, either because of their HDP or otherwise, about this possibility may help to pre-empt potential trauma.

Research into the management experiences of pregnant women with chronic hypertension, as distinct from medication treatment, is scant. Our study has highlighted the need for extra attention to be given to improve management pre-conception, during the pregnancy and postpartum. A qualitative study exploring knowledge and attitudes related to pregnancy and preconception health in women with chronic medical conditions, including chronic hypertension, found that the women had limited knowledge of the specific potential complications of pregnancy [ 32 ]. Some women in our study also displayed limited understanding of the potential risks that they may endure during pregnancy and thus had a lack of comprehension of the seriousness of the condition. Counselling women pre-conception regarding potential risks during pregnancy allows them to be more aware of what to expect [ 33 ]. Moreover, an open conversation about the information that the pregnant woman may have either from prior experience or ‘self-research’ would help to improve understanding as well as avoiding confusion and unnecessary anxiety. The provision of written material so that the women can refer to it when necessary would also be appropriate. Another facet of management of chronic hypertension pre-conception is the initial diagnosis of hypertension. Some women in our study were not aware of their BP readings before pregnancy and were diagnosed with hypertension quite early in pregnancy and thus classed as having chronic hypertension. Regular checking of BP in women of reproductive age at routine GP visits may help to identify chronic hypertension earlier. This can help in the planning of a pregnancy, or ensure that the BP is under control in the case of an unexpected pregnancy. Similarly, for those who have chronic hypertension and are prescribed antihypertensives, switching the medication to one that is safer during pregnancy, either pre-conception or as early as possible, can help to reduce fetal exposure and reduce the mother’s anxiety. Both GPs and community pharmacists have a role in counselling women of reproductive age who are prescribed an antihypertensive. A simple question as to whether the women is planning a pregnancy can help initiate the necessary conversation and trigger the switch to a safer alternative in a timely manner. Various resources are available to help make the decision to change the antihypertensive, including drug information lines at maternity hospitals. Moreover, a large number of women who had entered our study with chronic hypertension had developed the condition after a previous pregnancy that was affected by gestational hypertension or pre-eclampsia. Furthermore, our study found that many women developed chronic hypertension soon after a pregnancy complicated by HDP. This is supported by a recent systematic review and meta-analysis which reported that the risk of developing hypertension after HDP is highest in the early postpartum period [ 34 ]. The authors also suggested that diagnosis and targeted interventions to improve maternal cardiovascular health may need to be commenced in the immediate postpartum period [ 33 ]. We agree with this and call for a more integrated follow up with women in the postpartum period and beyond. This may involve the GP and the community pharmacist for easy accessibility for the women.

Although most women with chronic hypertension in our study were under a model of care involving an obstetrician and a physician, one was under midwifery care despite having chronic hypertension and being prescribed an antihypertensive. Although it is recognised by Australian guidelines for the management of HDP that midwives play a role in a multidisciplinary team in relation to management of HDP [ 4 , 35 ], they are not qualified to independently prescribe medication and manage cases of pregnant women with chronic hypertension requiring treatment. Similarly, a recent scoping review found that practising midwives worldwide lack knowledge on several aspects of pre-eclampsia diagnosis and care and have called for an increase in in-service training to increase midwives’ knowledge in this area [ 36 ]. It is therefore important that all pregnant women who have chronic hypertension be under the doctor model of care to monitor both mother and baby throughout the pregnancy.

Recommendations for practice

Good communication between the HCP and the patient is important to optimise management. Clear, direct and concise information about various facets of the management of HDP should be provided for all women who experience HDP.

Women who experience any form of HDP during pregnancy should be invited to be part of the decision-making pertaining to the monitoring of BP and progression to pre-eclampsia as well as the timing and mode of delivery when appropriate.

There should be a priority for women with chronic hypertension to be seen at the hospital under an obstetrician led model of care before 18 weeks, not only for the regular monitoring of BP and fetal progress but also for the timely prescription of low-dose aspirin before 16 weeks gestation for the prevention of pre-eclampsia. Furthermore, other health professionals, including psychologists and pharmacists, can be involved in the prenatal care of these women to address potential fear and anxiety as well as the optimal use of medication.

Women who have chronic hypertension and are of reproductive age should be informed of the potential risks of pregnancy and be switched to a pregnancy safe antihypertensive in the preconception stage.

Women who experience gestational hypertension or pre-eclampsia during pregnancy should have their BP monitored postpartum by the GP or the community pharmacist to identify any risk of developing severe cardiovascular events.

Recommendations for future research

Currently, much of the monitoring of HDP requires a hospital visit. Further research into the feasibility of telehealth for the monitoring of HDP, especially in mild cases will help to include patients in the decision-making. Moreover, future research into the role of the GP and the community pharmacist in the pre-pregnancy planning stage for those with chronic hypertension and postpartum for those with gestational hypertension or pre-eclampsia is warranted.

Strengths and limitations

This qualitative study is the first to use in-depth interviews to explore pregnant women’s experiences, perceptions and behaviours with regard to the management of HDP during pregnancy. Our study included women with all forms of HDP except HELLP and eclampsia, as the interviews were done when the women were in a comfortable, non-emergency situation. Participants varied in gestation stage, subtype of HDP, severity of HDP, ethnicity and socioeconomic status allowing for a wide range of views. The interviews were conducted during pregnancy thus reducing recall bias. This is in contrast to other qualitative studies which explored aspects of HDP in retrospect [ 27 , 35 , 37 ]. Recruitment was from two major public maternity referral hospitals in Melbourne with a widespread combined catchment including metropolitan, regional and rural areas. Participants did not include those in the first trimester of pregnancy, as most were scheduled to attend the antenatal clinics after 12 weeks gestation. Views of women with chronic hypertension during the first trimester of pregnancy may vary from those in the second and third trimesters and they were not captured . Women with poor English skills were excluded from the study, therefore, caution should be taken in the extrapolation of our findings to women from non-English speaking backgrounds.

The clinical management experiences of pregnant women with HDP were varied. Many women did not feel that they were well informed of treatment and management decisions and had a desire to be more informed and more involved in decision-making. Clear, concise information about various facets of HDP management including BP monitoring, administration of low dose aspirin in women with a high risk of developing pre-eclampsia, prescription of the appropriate antihypertensive, and planning for potential early delivery are required. In addition, cardiovascular pre-pregnancy planning and postpartum follow-up should be routinely offered to women.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to privacy surrounding participant information as stipulated in the written consent form, but are available from the corresponding author on reasonable request.

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Acknowledgements

We would like to thank the staff at both the Mercy Hospital for Women and the Royal Women’s Hospital for their help with this study. We would also like to thank all the women who participated.

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All authors contributed to the conception and design of the study. Patient recruitment and in-depth interviews were undertaken by AH. Data analyses and interpretation were performed by AH, KS and KR. The manuscript was written by AH and critically reviewed by all authors. All authors read and approved the final manuscript.

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Ethical approval was obtained from Mercy Health Human Research Ethics Committee Heidelberg-Melbourne (R12/62) 08/01/2013, The Royal Women’s Hospital Research and Human Research Ethics Committee Parkville-Melbourne (R13/18) 12/07/2013 and Monash University Human Research Ethics Committee Clayton-Melbourne (CF13/117) 18/01/2013. Informed written consent was obtained prior to each interview, which included permission to audio record the conversation and use quotations when anonymously reporting and publishing the results. All methods were carried out in accordance with relevant guidelines and regulations of the ethics committees.

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Helou, A., Stewart, K., Ryan, K. et al. Pregnant women’s experiences with the management of hypertensive disorders of pregnancy: a qualitative study. BMC Health Serv Res 21 , 1292 (2021). https://doi.org/10.1186/s12913-021-07320-4

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DOI : https://doi.org/10.1186/s12913-021-07320-4

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Pregnancy-Induced Hypertension

Jennifer Ribowsky , MS, RPA-C Caitlin Henderson , S-NP, RN(BSN)

Women with pregnancy-induced hypertension (PIH) are at increased risk for preeclampsia, cesarean delivery, renal dysfunction, and placental abruption; associated risks to the fetus include intrauterine growth restriction, preterm delivery, low birth weight, and neonatal ICU admission. Ongoing monitoring for increased hypertension and proteinuria, consideration of expectant management or labor induction, and appropriate use of antihypertensive therapy are essential components in the management of women with PIH.

Hypertensive disorders represent one of the most common medical complications of pregnancy. 1,2 Based on a nationwide inpatient sample examining more than 36 million deliveries in the United States, the prevalence of associated hypertensive disorders increased from 67.2 per 1,000 deliveries in 1998 to 83.4 per 1,000 deliveries in 2006. 3 Pregnancy-induced hypertension (also referred to as gestational hypertension or hypertensive disorder of pregnancy) 4-6 is estimated to affect 6% to 8% of US pregnancies. 1,2

Women who develop severe hypertension during pregnancy may experience adverse effects similar to those associated with mild preeclampsia. 2,7,8 In the mother, these may range from elevated liver enzymes to renal dysfunction; and in the fetus, from preterm delivery to intrauterine restriction of fetal growth. 7,8

This article will review the risk factors, clinical presentation, diagnosis, and management of pregnancy-induced hypertension. A brief discussion of preeclampsia as it relates to gestational hypertension will be included (see Table 1 2,6,9 ).

sample case study pregnancy induced hypertension

Classification, Definitions

Pregnancy-induced hypertension (PIH) is classified as mild or severe . Mild PIH is defined as new-onset hypertension (systolic blood pressure ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg), occurring after 20 weeks’ gestation. The majority of cases of mild PIH develop beyond 37 weeks’ gestation, and in these cases, pregnancy outcomes are comparable to those of normotensive pregnancies. 2,7,8

Severe PIH is defined as sustained elevated blood pressures of ≥ 160 mm Hg systolic and ≥ 110 mm Hg diastolic. In prospective cohort studies in which calcium supplementation and low-dose aspirin use were being investigated for prevention of preeclampsia in healthy pregnant women, those who were severely hypertensive were found to be at increased risk for certain maternal comorbidities (eg, cesarean delivery, renal dysfunction, elevated liver enzymes, placental abruption) and perinatal morbidities (delivery before 37 weeks’ gestation, low birth weight, fetal growth restriction, and neonatal ICU admission), compared with patients who were normotensive or mildly hypertensive. 7,8

The diagnosis of PIH may later be amended or replaced by one of the following diagnoses: preeclampsia, if proteinuria (to be defined and discussed later) develops; chronic hypertension, if blood pressure remains elevated past 12 weeks postpartum; or transient hypertension of pregnancy, if blood pressure normalizes by 12 weeks postpartum. 5,6,10

Pathophysiology and Risk Factors

Although the pathophysiology of PIH is not well understood, the pathogenesis of preeclampsia likely involves abnormalities in the development, implantation, or perfusion of the placenta, and often leads to impaired maternal organ function. 6,11 It is not clear whether PIH and preeclampsia are two different diseases that share a manifestation of elevated blood pressure or whether PIH represents an early stage of preeclampsia. 4,12 However, women with preexisting hypertension, especially severe hypertension, are at increased risk for preeclampsia, placental abruption, and fetal growth restriction. 2

There are some similarities and some distinct differences among the clinical features and risk factors associated with PIH, compared with those of preeclampsia. Risk factors for PIH include a pre-pregnancy BMI of 25 or greater, PIH and/or preeclampsia in previous pregnancies, and history of renal disease, cardiac disease, or diabetes. The most important risk factors for preeclampsia include preexisting diabetes or nephropathy, chronic hypertension, PIH or preeclampsia in a previous pregnancy, maternal age younger than 18 or older than 34, African-American ethnicity, first pregnancy, multiple pregnancy, history of preeclampsia in the patient’s mother or sister, obesity, autoimmune disease, and an interval between pregnancies longer than 10 years. 4-6,13-15

The risk for preeclampsia in patients with PIH is approximately 15% to 25% 12,16 ; according to Magee et al, 6 35% of women with PIH onset before 37 weeks’ gestation develop preeclampsia. 6,12,17 The risk for recurrence of PIH in subsequent pregnancies is about 26%, whereas women who experience preeclampsia in one pregnancy have a comparable risk for PIH or preeclampsia (about 14% each) in subsequent pregnancies. 18

Clinical Presentation and Diagnostic Evaluation

Blood pressure should be measured and recorded at every prenatal visit, using the correct-sized cuff, with the patient in a seated position. 5 Gestational hypertension is a clinical diagnosis confirmed by at least two accurate blood pressure measurements in the same arm in women without proteinuria, with readings of ≥ 140 mm Hg systolic and/or ≥ 90 mm Hg diastolic. It should then be determined whether the patient’s hypertension is mild or severe (ie, blood pressure > 160/110 mm Hg). The patient with severe PIH should be evaluated for signs of preeclampsia, as discussed below.

Patients with mild PIH are often asymptomatic, and the diagnosis is made at a prenatal visit as a result of routine blood pressure monitoring; this is one of many reasons to encourage early and regular prenatal care. Blood pressure may be higher at night in hypertensive disorders of pregnancy. 10

Recommended reading

Effects of a Case Management Program for Women With Pregnancy-Induced Hypertension

Affiliations.

  • 1 PhD, RN, Assistant Professor, Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan.
  • 2 PhD, RN, Professor, School of Nursing, National Defense Medical Center, Taipei, Taiwan.
  • 3 BSN, RN, Case Manager, Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan.
  • 4 PhD, RN, Distinguished Professor, Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan.
  • 5 PhD, RN, Associate Professor, Department of Nursing, College of Medicine, National Cheng Kung University, and National Cheng Kung University Hospital, Tainan, Taiwan.
  • PMID: 34432727
  • DOI: 10.1097/jnr.0000000000000450

Background: Pregnancy-induced hypertension (PIH) is a leading cause of maternal and fetal morbidity and mortality. Although case management programs have been proposed to improve maternal and fetal outcomes in high-risk pregnancies, limited data are available regarding the effect of case management on women with PIH.

Purpose: The aim of this study was to evaluate the effect of an antepartum case management program on stress, anxiety, and pregnancy outcomes in women with PIH.

Methods: A quasi-experimental research design was employed. A convenience sample of women diagnosed with PIH, including preeclampsia, was recruited from outpatient clinics at a medical center in southern Taiwan. Sixty-two women were assigned randomly to either the experimental group (n = 31) or the control group (n = 31). The experimental group received case management for 8 weeks, and the control group received routine clinical care. Descriptive statistics, independent t or Mann-Whitney U tests, chi-square or Fisher's exact tests, paired t test, and generalized estimating equations were used to analyze the data.

Results: The average age of the participants was 35.1 years (SD = 4.5). No significant demographic or clinical differences were found between the control and experimental groups. The results of the generalized estimating equations showed significantly larger decreases in stress and anxiety in the experimental group than in the control group. No significant differences were identified between the two groups with respect to infant birth weeks, infant birth weight, average number of medical visits, or frequency of hospitalization.

Conclusions/implications for practice: The nurse-led case management program was shown to have short-term positive effects on the psychosocial outcomes of a population of Taiwanese patients with PIH. These results have important clinical implications for the healthcare administered to pregnant women, particularly in terms of improving the outcomes in those with PIH.

Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc.

Publication types

  • Randomized Controlled Trial
  • Case Management
  • Hypertension, Pregnancy-Induced* / therapy
  • Pre-Eclampsia* / therapy
  • Pregnancy Outcome
  • Prenatal Care

Pregnancy Induced Hypertension

sample case study pregnancy induced hypertension

Some complications of pregnancy only develop during the instance that the woman is pregnant, while others have already been there even before the pregnancy has started. These complications are just roadblocks towards a healthy pregnancy, and we are the drivers who should carry our passengers, our patients, to safety by avoiding these roadblocks. Pregnancy-induced hypertension (PIH), also known as gestational hypertension or pregnancy-related high blood pressure, is one such condition that demands careful monitoring and expert nursing care.

This article aims to provide nursing professionals with a comprehensive guide to understanding, identifying, and managing pregnancy-induced hypertension. By delving into the pathophysiology, risk factors, and clinical manifestations of PIH, we seek to equip nurses with the knowledge and skills necessary to provide optimal care for mothers facing this challenge.

Table of Contents

What is pregnancy induced hypertension, pathophysiology, gestational hypertension, mild preeclampsia, severe preeclampsia, hellp syndrome, risk factors, signs and symptoms, diagnostic tests.

  • Medical Management
  • Surgical Management

Nursing Care Plan and Management

  • Pregnancy induced hypertension (PIH) is a condition wherein vasospasm occurs during pregnancy in both the small and large arteries in the body.
  • Also known as gestational hypertension.
  • Pregnancy Induced Hypertension is a form of high blood pressure in pregnancy.
  • It occurs in about 5 percent to 8 percent of all pregnancies.
  • It is a condition in which vasospasm occurs during pregnancy in both small and large arteries. With high blood pressure, there is an increase in the resistance of blood vessels. This may hinder blood flow in many different organ systems in the expectant mother including the liver , kidneys, brain , uterus, and placenta .
  • Originally, it was called toxaemia because researchers pictured a toxin of some kind being produced by the woman in response to the foreign protein of the growing fetus, the toxin leading to the typical symptoms. No such toxin has ever been identified.
  • Increased cardiac output occurs with pregnancy, and it can injure the epithelial cell of the arteries.
  • Prostaglandin, a vasodilator, may also contribute to the injury .
  • Reduced responsiveness of the blood vessels to the blood pressure is lost.
  • There is vasoconstriction, and blood pressure increases.

Classifications

  • A woman is said to have Gestational Hypertension when she develops an elevated blood pressure (140/90 mmHg) but has no proteinuria or edema .
  • Perinatal mortality is not increased with simple gestational hypertension, so no drug therapy is necessary.
  • Systolic blood pressure greater than 30 mmHg and diastolic blood pressure greater than 15 mmHg above pregnancy values.
  • No edema, no proteinuria and blood pressure returns to normal after birth.
  • A woman is said to be mildly preeclamptic when her blood pressure rises to 140/90 mmHg, taken on two occasions at least six (6) hours apart.
  • In addition to hypertension, a woman has proteinuria (1+ or 2+ on a reagent test strip on a random sample).
  • A weight gain of more than 2 lbs/week in the second trimester or 1 lb/week in the third trimester usually indicates abnormal tissue fluid retention.
  • A woman has passed from mild to severe preeclampsia when her blood pressure has risen to 160 mmHg systolic and 110 mmHg diastolic or above on at least two occasions 6 hours apart at bed rest .
  • Marked proteinuria. 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample and extensive edema are also present.
  • With the severe preeclampsia, the extreme edema will be noticeable as puffiness in a woman’s face and hands.
  • It is most readily palpated over bony surfaces. The woman may manifest oliguria (altered renal function), elevated serum creatinine (more than 1.2 mg/dL); cerebral or visual disturbances (blurred vision ); thrombocytopenia and epigastric pain .

This is the most severe classification of PIH. A woman has passed into this stage when cerebral edema is so acute that seizure or coma occurs. With eclampsia, the maternal mortality is high from cause such as cerebral hemorrhage , circulatory collapse or renal failure . The fetal prognosis in eclampsia is poor because of hypoxia and consequent fetal acidosis. The manifestations are the same accompanied by seizures.

Severe Preeclampsia (HELLP Syndrome) Nursing Mnemonic

HELLP syndrome is a complication of severe preeclampsia or eclampsia. HELLP syndrome is a group of physical changes including the breakdown of red blood cells, changes in the liver and low platelets (cells found in the blood that are needed to help the blood to clot in order to control bleeding ).

There are certain factors that contribute to the occurrence of pregnancy induced hypertension.

  • Women of color . Hypertension is most common to these women due to genetic makeup of their race.
  • Multiple pregnancies . Women who have undergone multiple pregnancies are more compromised with hypertension.
  • Primiparas who are 20 years and older . This group has an increased risk for pregnancy induced hypertension than women who are 40 years old and above.
  • Women from low socioeconomic backgrounds . These women may have a poor diet due to their low socioeconomic background, which could contribute greatly to hypertension.
  • Underlying disease . This disease might contribute to the occurrence of pregnancy induced hypertension.

These signs and symptoms, once detected, would indicate pregnancy induced hypertension

  • Hypertension. An increase in the usual blood pressure of the woman is the first indicator of this disease.
  • Proteinuria. Protein leaks out during this condition and can be detected in the urine.
  • Edema. Since protein has already leaked out and it is responsible for containing water inside the vessels, edema starts to occur.

Diagnostic tests would be ordered by the physician to determine the presence of pregnancy induced hypertension.

  • Urinalysis. This is one of the most common diagnostic tests that determine the presence of protein in the urine. This is usually indicative of pregnancy induced hypertension.

Medical Management

Medications and other therapies are instituted by the physician to reverse pregnancy induced hypertension.

  • Antiplatelet therapy. There is an increased tendency for platelets to cluster along the vessel walls, so a mild antiplatelet agent is ordered by the physician.
  • Administer medications to prevent eclampsia. To avoid progression of the disease to eclampsia, hydralazine, nifedipine , and labetalol may be prescribed to reduce hypertension.

Surgical Management

No surgical interventions are needed to manage pregnancy induced hypertension. They can be managed by medications and interventions imposed or ordered by health care providers.

Nurses also have a role in reducing the blood pressure of the patient. These are just simple interventions but could create a dramatic effect when applied properly.

Please visit 7 Preeclampsia & Gestational Hypertensive Disorders Nursing Care Plans for a comprehensive nursing care plan and management guide.

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Open Access

Peer-reviewed

Research Article

Determinants of pregnancy-induced hypertension on maternal and foetal outcomes in Hossana town administration, Hadiya zone, Southern Ethiopia: Unmatched case-control study

Roles Writing – original draft

* E-mail: [email protected]

Affiliation Department of Nursing College of Medicine and Health Science, Wachemo University, Hossana, Ethiopia

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Roles Writing – review & editing

Roles Data curation

Affiliation Department of Public Health College of Medicine and Health Science, Wachemo University, Hossana, Ethiopia

Affiliation Department of Health Management and Economics, School of Public Health, Tehran University of Medical Science, Tehran, Iran

  • Getachew Ossabo Babore, 
  • Tsegaye Gebre Aregago, 
  • Tadesse Lelago Ermolo, 
  • Mangistu Handiso Nunemo, 
  • Teshome Tesfaye Habebo

PLOS

  • Published: May 12, 2021
  • https://doi.org/10.1371/journal.pone.0250548
  • Peer Review
  • Reader Comments

Fig 1

Globally, 292,982 women die due to the complications of pregnancy and childbirth per year, out of those deaths 85% occurs in Sub Saharan Africa. In Ethiopia, pre-eclampsia accounts for 11% of direct maternal deaths.

To determine maternal and foetal outcomes of pregnancy-induced hypertension among women who gave birth at health facilities in Hossana town administration.

Institutional based unmatched case-control study was conducted among women, who gave birth at health facilities from May 20 to October 30, 2018. By using Epi-Info version 7; 207 sample size was estimated, for each case two controls were selected. Two health facilities were selected using a simple random sampling method. Sample sizes for each facility were allocated proportionally. All cleaned & coded data were entered into Epi-info version 3.5.1 and analysis was carried out using SPSS version 20. Multivariate analysis was performed to determine predictors of pregnancy-induced hypertension at a p-value of <0.05.

Women between 18 to 41 years old had participated in the study with the mean age of 26.00(SD ±4.42), and 25.87(SD ±5.02) for cases and controls respectively. Out of participants 21(30.4%) among cases and 21(15.2%) among controls had developed at least one complication following delivery. 12 (17.4%) and 8 (5.7%) foetal deaths were found in cases and controls groups respectively whereas 15.6% from cases and 3.6% from controls groups women gave birth to the foetus with intra-uterine growth retardation. Women gravidity AOR = 0.32 [95% CI (0.12 0.86)], Previous history of pregnancy-induced hypertension AOR = 22.50 [95% CI (14.95 16.52)] and educational status AOR = 0.32[95% CI (0.12, 0.85)] were identified as predictor of pregnancy-induced hypertension.

Women with a previous history of pregnancy-induced hypertension had increased risk of developing pregnancy-induced hypertension, whilst ≥ 3 previous pregnancies and informal educational status decrease odds of developing pregnancy-induced hypertension.

Citation: Babore GO, Aregago TG, Ermolo TL, Nunemo MH, Habebo TT (2021) Determinants of pregnancy-induced hypertension on maternal and foetal outcomes in Hossana town administration, Hadiya zone, Southern Ethiopia: Unmatched case-control study. PLoS ONE 16(5): e0250548. https://doi.org/10.1371/journal.pone.0250548

Editor: Frank T. Spradley, University of Mississippi Medical Center, UNITED STATES

Received: May 1, 2020; Accepted: April 9, 2021; Published: May 12, 2021

Copyright: © 2021 Babore et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All the necessary data and materials are incorporated in the article and Supporting Information . Any further requests will be addressed by the corresponding author upon reasonable request.

Funding: The authors received no specific funding for this work from any source. all of us doing for academic qualification and put finger print for scientific society.

Competing interests: The authors declare that no competing interests.

Introduction

Pregnancy and childbirth are natural processes, which comes up with multiple consequences. A hypertensive disorder is one of the pregnancy consequences which is a major alarming cause for maternal, perinatal morbidity and mortalities [ 1 ]. The term hypertension in pregnancy is commonly used to describe a wide spectrum of the patient who may have only mild elevations in blood pressure to severe organ dysfunction. Thus, it is accompanied by minor to major complications. Worldwide hypertensive disorder in pregnancy/HDP affects 5–22% and it is responsible for 5–10% of complications in all pregnancies [ 2 – 4 ] .

Among four classes of HDP, preeclampsia remains a leading cause, which needs rigorous public intervention for better outcome of foetus and mother, and Preeclampsia affects up to 5–8% out of all pregnancies [ 5 ]. Also, preeclampsia is a unique form of hypertension during pregnancy which usually occurs after 20 weeks of gestation. If the early investigation and appropriate management are not undertaken for the women diagnosed with pre-eclampsia. It progress to a severe form called eclampsia, which end-up with maternal as well as foetal adverse outcomes like abruption placenta, acute renal failure/ARF, intravascular coagulation, intra-uterine growth retardation/IUGR, and stillbirth [ 6 ]. Therefore, the origin for eclampsia is pre-eclampsia (Eclampsia is the definition of Preeclampsia plus ≥ +2 proteinuria plus the occurrence of convulsion or coma) [ 7 ].

Studies suggested that either pre-existing pregnancy-induced hypertension/PIH or pregnancy changes could be responsible for the occurrence of pre-eclampsia. In a multicentre study approximately, 30% of hypertensive disorders of pregnancy were occurred due to chronic hypertension while 70% of the cases were diagnosed as gestational hypertension or pre-eclampsia [ 8 ]. Regardless of new-onset or pre-existing occurrences, the harmful effects of preeclampsia and eclampsia upraised from mother to child, family to the country and its severity is from trivial to life-threatening. Still, it has remained a significant public health threat in both developed and developing countries [ 9 ].

PIH denotes women’s systolic blood pressure/SBP ≥ 140mmHg, and diastolic blood pressure/DBP ≥ 90mmHg on two or more consecutive measures without proteinuria after 20 weeks of gestation; pre-eclampsia is characterized as when pregnant women presented with SBP ≥ 140mmHg and DBP ≥ 90mmHg on two or more consecutive measures within 4 hours interval with the presence of proteinuria that occurs after 20 weeks of gestation whereas eclampsia denotes the occurrence of convulsion plus proteinuria +2 or more and sign and symptom of severe pre-eclampsia for the women who fulfil the definition of PIH [ 10 – 12 ].

Pre-eclampsia and eclampsia are the second direct cause for maternal death which accounts for 10 to 15% of maternal deaths worldwide [ 13 ]. The incidence of pre-eclampsia has significant variation in different parts of the continents. For instance, 4% in Africa, 3.8% in Europe, and 4.2% in the western Pacific region [ 14 ]. Moreover, the prevalence of pre-eclampsia throughout the country has vast variation, in Jima University specialized hospital, it was 51.8%, three southwest Ethiopia hospitals 6.3% [ 15 ], and in seven Tigray hospitals 50% [ 16 ].

Globally, 292,982 women died due to the complications of pregnancy and childbirth. Out of those deaths, 85% have occurred in Sub Saharan Africa/ SSA, yet the majority of those deaths occurred in low resource settings, and most of them could have been preventable [ 17 , 18 ]. Furthermore, the highest share of maternal death has been reported in Africa as compared to other regions. Maternal death due to pregnancy-related causes is 1 in 4,000 in Europe and 1 in 16 in African countries [ 18 , 19 ]. Likewise, The probability of a 15 year-old girl eventually dying from a maternal cause in Africa was as high as 1 in 37- as compared to 1 in 3400 in the European region [ 20 ].

According to the latest joint trend review study in maternal mortality conducted by United Nation Population Division/UNPD, World health organization/WHO and World Bank, the proportion of mothers dying per 100,000 live births has declined from 380 to 210 in 1990 to 2013 [ 21 ]. Besides, there was a slight reduction in maternal mortalities in the last three consecutive Ethiopian demographic health surveys/EDHs; MMR was 667, 665 and 412 per 100,000 life birth and all those deaths might have happened as a result of direct or indirect causes [ 22 ]. On the other hand, a trend review study from 1980 to 2012 in Ethiopia, on maternal death reported that as a result of hypertensive disorder of pregnancy/HDP, maternal death has increased from 4%-29%. In-addition to the death trend, the review pointed out the major direct obstetric complications (sepsis, haemorrhage, unsafe abortion, obstructed labour) including pre-eclampsia, accounts for 85% of maternal death. Whereas pre-eclampsia solely accounts for 11% of maternal death [ 23 , 24 ]. Whilst pre-eclampsia and Eclampsia contribute to 53% of maternal and 62.7% of perinatal complications during pregnancy and birth [ 25 ].

HDP especially preeclampsia, in primigravida women is 2 times more risky than multigravida [ 26 , 27 ]. Impacts of pre-eclampsia and eclampsia are disproportional in both developed and developing countries which are seven times higher in developing countries than in developed worldwide [ 28 ].

Impacts of Pre-eclampsia and eclampsia on maternal and foetal outcomes are enormous, which results in life-threatening events to death. For instance, it increases the risk of placenta abruption, postpartum haemorrhage/PPH and intra-uterine growth retardation. According to the WHO multicentre survey, the risk of perinatal death among women with preeclampsia and eclampsia increased 3 and 5 folds respectively, as compared to women with no preeclampsia or eclampsia [ 26 , 29 , 30 ]. Still, preeclampsia is one of the major causes of perinatal death in developing countries, accounts for 20–50% of deaths [ 31 ]. In Ethiopia, eclampsia accounts for 35.7% of maternal death [ 32 , 33 ].

Studies were done abroad and our country revealed that pregnancy-induced hypertension has been associated with poor maternal and prenatal outcomes and loos of life [ 34 ]. Case control hospital-based study done in India reported that 10, 8, 3 and 2 complications of Haemolysis, Elevated Liver enzymes, and Low Platelet count/HELLP syndrome, PPH, Infection and ARF respectively [ 35 ]. On another case control study conducted by Guduri GB revealed that there were 18%, 2% PPH and 36%, 7% preterm complication, among cases and controls respectively [ 36 ].

Studies done in different regional hospitals, Ethiopia reported various proportions of maternal complications and deaths following delivery occurred as a result of pre-eclampsia/eclampsia. The Eastern part of, Ethiopia finding revealed that 53% maternal and 62.7% perinatal complication with a fatality rate of 11% [ 25 ], in Woliata Sodo University teaching Hospital 48.89% perinatal complication and 8.89% perinatal deaths [ 37 ]. In Zewuditu Memorial Hospital, among women had developed PIH, 131 (52.4%) of them developed complication whilst 31.1% of them experienced with HELLP syndrome [ 38 ].

Different studies noted that previous history of pregnancy-induced hypertension, age, and educational status were independent risk factors for the development of preeclampsia. In addition to these, occupation, gravidity, family history of hypertension, gestational diabetic Mellitus and residence had a significant statistical association with preeclampsia [ 39 – 42 ].

Yet, there have been different studies conducted to explore PIH in Ethiopia, but there was no study conducted on predictors of pregnancy-induced hypertension in the study area. Thus, to come up with effective public as well as clinical intervention approach and strong policy development direction, conducting root cause identification research is essential. Therefore, the main objective of this study is to determine maternal and foetal outcomes of pregnancy-induced hypertension among women who gave birth at Public health facility in Hossana town administration, Hadiya zone, Southern Ethiopia: unmatched case control [ Fig 1 ].

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Legend: PIH: Pregnancy-induced hypertension, HDP: hypertensive disorder of pregnancy, Hx: history, ANC: antenatal care, GA: gestational age.

https://doi.org/10.1371/journal.pone.0250548.g001

Methods and material

The study was conducted in Hossan town administration, Hadiya Zone, South Nation Nationality and People Regional state/SNNPR, Ethiopia. Hadiya zone has ten woredas and two town administrations. According to the Hadiya Zone Finance and Economic Development office statistics, the total population of the zone was 2,486,242 of which 1,218,258 were men whereas 1,267,983 of them were female.

Hossana town is located in the northern part of SNNPR state. It is 232 KM far from the country’s capital city to the south and 120 KM from the regional capital town. The town administration is classified into 3 subs administrative with a total of 8 kebeles. According to the Hossana town administrative office, the current (2018/2019) projection estimated total population was 104,053 whereas 50,986 males and 53, 067 of them were females. Among the total town population, women within the reproductive age group encompass 24,244 from them the estimated number of women who are eligible to be pregnant in the current physical year were 8,388 [ 43 ].

The town has one teaching hospital which has been serving more than 3, 548,800 million people from the entire Hadiya Zone and partial part of kembeta and Silte Zone. As well, the town has three health centres, one private surgical hospital, and more than 15 private clinics.

Study design and period

Institutional based unmatched case control study was conducted in OB/GYN department of the selected public health facilities, from May 20/2018 to October 30/2018.

All pregnant women who were on follow up after 20 weeks gestational age and visit health facilities for delivery service and screened as of having pregnancy-induced hypertension registered in the OB/GYN departments of the respective facilities.

Pregnant women who have no PIH in the same period and the same health facilities and who came for delivery service after 20 weeks of gestational age.

Source population

The source population of the study were all women, who have been on follow-up care unit and visit facilities for delivery service in Public Health facilities those resided in Hossana town administration.

Study population

All women who were selected using systematic sampling method applying population proportionate to sample size (PPS) from randomly selected public health facilities among women who had been on follow-up care unit and visit the health facility for delivery service whose gestational age above 20 weeks.

Eligibility criteria

Inclusion criteria..

All pregnant women who were on flow up and visited selected public health facility for delivery service whose gestational age above 20 weeks were included. For women representing cases, they diagnosed having Pregnancy-induced hypertension as of her SBP ≥140mmHg and DBP ≥90 mmHg on two separate reading which measure within at least four hours apart, plus a dipstick reading +1 and above. For women represent Controls, women within the same health facilities who were attending delivery care was not diagnosed as having Pregnancy-induced hypertension.

Exclusion criteria.

Women who didn’t indweller in respective town administrative sub towns and no longer stay at Hossan town administration for more than six months.

Women with a known diagnosis for Epilepsy and women who were not voluntary to give consent also excluded from the study.

Simple size and sampling technique

Sample size..

The sample size for this study was computed based on the comparison of proportion for case control study by using Epi-info version 7 for windows. According to a study conducted by Eskeziaw Agedew [ 39 ], by considering the factors gravidity and maternal age had an association with PIH. Being multigravida and age during current pregnancy between 25–30 years which have a significant association with pregnancy-induced hypertension with case to control ratio 1:2 and Odds ratio (OR) = 4 and using the following assumptions: power 80%, confidence level 95% ( Table 1 ). The final sample size was taken from the women who were multigravida by adding 10% non-response rate. Thus, an estimated sample was employed for case 69 and 138 for controls yielding a total sample of 207.

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https://doi.org/10.1371/journal.pone.0250548.t001

Sampling technique

To select a study unit two Public Health facilities were selected randomly among four facilities. Considering the two months report data from the health management information system/HMIS office sample size allocated proportionally by using proportionate to population size for cases and controls. All newly registered pregnant women who were more than 20 gestational weeks suffered from pregnancy-induced hypertension were selected representing the cases. For each case, women who registered for ANC follow up and had given delivery whose gestational age ≥20 weeks, but hadn’t experienced with PIH at the same time in the same facilities were taken as control. To select controls, a list of total women the MCH department registration book for those who have ANC follow up after 20 weeks of gestation age was considered as a sampling frame. The estimated sample size for this study (n) was divided by a total number of women (N) registered in randomly selected HFs during the last two months which yield proportionate (P). Then through multiplying proportionate value with two months sample, a proportional sample was allocated for each selected health facilities. Finally, by employing a systematic sampling method based on the k th value sampling unit was traced in respective facilities. The sampling procedure was presented ( Fig 2 ).

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HC: health centre, NEMMTH: Nigest Eleni Mohomod Memorial Teaching Hospital, n: proportional allocated sample size.

https://doi.org/10.1371/journal.pone.0250548.g002

Data collection method, tools and procedures

Structured and pretested questionnaires which was prepared in English and translated to Amharic and then translated back into English again to assure consistency of tool, which developed from reviewing different literature was used in this study.

Data were collected by 4 BSc midwives, 2 BSc Nurses supervised and monitored during the data collection phase by using structured questionnaires whereas the principal investigator undertakes the overall coordination. Data were collected from women who gave birth in the OB/GYN department, for each case, two controls were interviewed on the same day and health facilities. Participant’s medical charts were also reviewed to obtain biomedical laboratory data at the same time.

Data quality control measures and management

Before the actual data collection date, data collectors & supervisors were trained concerning the overall issue of data collection format like, in time data collection following delivery, completeness, participant confidentiality and consistency.

One week before the actual data collection date, research tool was tested on 13 women who gave birth at Doyogena primary hospital, validity checked then a lot amendment was undertaken.

Every day, the principal investigator and supervisors were checked data for completeness and incomplete questionnaires were discarded. Cross-checked and coded data were entered into Epi-info software version 3.5.1. For further analysis and data cleaning, it was exported to SPSS (statistical package for social science) version 20.

Data analysis

To identify the proportion of the pregnancy induce hypertension impact on maternal and foetal outcome in-relation to outcome variable cross-tabulation frequencies were done. Cross tabulation was also employed to test the relation of variables against with outcome variable. Bivariate logistic regression was conducted to select candidate variables for multivariate analysis at P-value < 0.05. Finally, to determine predictors of outcome variables multivariate analysis was employed.

Data was described and presented using cross-tabulation value to for descriptive findings and interpreted by looking at a variable that has an association with outcome variables on multivariate analysis with a 95% confidence interval for AOR.

Study variables

Dependent variable..

Foeto-maternal outcomes of Pregnancy Induced Hypertension

Independent variable.

Socio demographic variables . Maternal age, residence, educational status, occupation and monthly income.

Obstetrics variables . Gravidity, number of parity, gestational age at delivery, number ANC follow up, number of babies (twin).

Medical variables . Previous history of pregnancy induced HTN, History of D/M, anaemia and renal disease.

Hypertensive disorder sign and symptoms of pregnancies on admission . Level of blood pressure during admission/presentation, vomiting, proteinuria, typical symptoms (oedema, blurred vision, headache and epigastric pain).

Ethical consideration

Ethical approval was obtained from IRB of WCU, Official letter for zonal/woreda health department was written from University research and community service V/P office and a cooperation letter was written from respective woreda office managers to the randomly selected health facilities.

Operational definitions of terms

Hypertensive disorders of pregnancy..

Includes chronic hypertensive and pregnancy induced hypertension, regardless of previous history of hypertensive disorder.

Pregnancy-induced hypertension.

Hypertension developed after 20 weeks of gestation where SBP ≥ 140mmHg and DBP ≥ 90mmHg, within two consecutive reading which measured 4–6 hours apart without proteinuria among mothers who were attended delivery unit at health facilities among previously normotensive women.

Preeclampsia.

The new onset of hypertension with SBP ≥ 140 and DBP ≥ 90 mmHg, within two reading which measured 4–6 hours interval with the presence of proteinuria with or without oedema which occurred after 20 weeks of gestation.

Mother with DBP greater than or equal to 110mmHg after 20 weeks of gestation and in-addition to the features of pre-eclampsia having one or more episode of convulsion or coma plus proteinuria + 2 or more.

Pregnancy outcome.

Any women who had at least one prenatal as well as maternal unfavourable outcome after delivery

Maternal complication.

Any mothers had at least one complication among who had attended delivery at Hospital.

Gestational age.

The duration of gestation is measured from the first day of last menstrual period more than 20 weeks for this study.

Foetal outcomes.

Any diagnosed complication or death confirmed after delivery.

Socio-demographic characteristics

Among a total of 207 participants, 69 cases and 139 controls women have participated in the study. Women from the age of 18–41 participated in the study while their mean age was 26.00 (SD ± 4.42), 25.87 (SD ± 5.02) for cases and controls respectively. Two women were participated in the study where their age was below legally eligible for marriage. The majority 97 (47.3%) participants’ were house-hold wives, 9(4.3% of them were students and 69 (42.9%) had no formal education.

Reproductive history and pre-existing medical illness during current pregnancy

Among women who had ANC visits three and above, 34 (52.3%) from cases and 72 (55.0%) from control were not developed PIH. Women with a high frequency of ANC follow-Up had a low proportion of becoming hypertensive on current pregnancy while among women who had no ANC follow-up, 4 from cases and 10 from controls groups had developed pregnancy-induced hypertension.

More than one-third of the study participants were primigravida among them 34 (31.5%) were not know their LNMP. However, 180 (86.9%) didn’t attend the minimum expected ANC follow up, only 16 (7.7%) had four and above ANC follow up. Seven women among cases and 44 women from control groups gave birth by caesarean section, but the largest proportion 62 (89.8%) of women from cases gave birth via spontaneous vaginal delivery/SVD as compared with controls 94 (68.1%).

Among all interviewed women, 29 (14.0%) were experienced with pre-existing medical illness includes: diabetic Mellitus, anaemia and non-pregnancy induced hypertension 4.3%, 5.3% and 3.9% respectively. A high proportion of women from cases 14 (20.3%) had medical problems as compared to controls 15 (10.9%). Out of the total cases that participated in this study; twenty-four women had a previous history of PIH. On the occasion of health facility arrival, 120 (57.9%) women were admitted with pushing labour pain, but the remaining were came up with one or more features rather than labour pain ( Table 2 ).

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https://doi.org/10.1371/journal.pone.0250548.t002

Even though the DBP range from 90 to 144 mmHg among cases the mean DBP, 104.13 (SD ± 9.20) was above the cut-off point of the normotensive women. Perinatal delivered from women with cases experienced with an average of 0.7 complications. On the occasion of reception for delivery service and follow-up care in addition to having high blood pressure, every woman from cases was admitted with at least of two suggestive clinical features for PIH whereas controlled had less than 1 clinical feature ( Table 3 ).

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https://doi.org/10.1371/journal.pone.0250548.t003

Maternal and fetal outcomes

A total of 69 women with cases participated in the study and showed a potential effect on maternal and perinatal health. Among the interviewed cases, 11 (15.9%) of them were developed eclampsia. On the occasion of the arrival to health facility among women who had developed eclampsia, only 3 (27.2%) of them were comatose on the occasion of the arrival of health facility. For all Women who developed PIH urine test was performed and a test result had shown a minimum +1 proteinuria for the dipstick test.

Among the total of interviewed cases, 21(30.4%) women have developed at least one complication following delivery. The majority of complications were 13 PPH and 7 disseminated intravascular coagulopathy/DIC. Moreover, PIH has a potential effect on maternal as well as perinatal outcomes; perinatal borne from women with PIH more likely to develop complication than normotensive women. Out of 55, alive births among cases 32 (58.2%) had at least one complication, but out of total alive births, 32.9% (n = 68) perinatal hadn’t any complication. From 20 perinatal deaths, 12 (17.4%) was reported from women who had developed PIH. Among 13 foetal IUGR, 8 of them were from cases as far as women diagnosed for PIH 3.7 times more risky to causes foetal IUGR than normotensive women ( Table 4 ).

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https://doi.org/10.1371/journal.pone.0250548.t004

Pregnancy-induced hypertension and associated factors

Binary logistic regression with a confidence level of 95%, (α = 0.05) was conducted and variables which have statistically significant at p-value < 0.05 were selected as candidate variable for the last model that determine predictors of pregnancy-induced hypertension among women gave birth at health facilities.

Finally, variables entered into the last model and multivariate analysis was performed. The Previous history of pregnancy-induced hypertension increased odds of developing pregnancy-induced hypertension by 22 folds, [95% CI (6.313, 80.204)], three and above previous pregnancies decreases odds of pregnancy-induced hypertension AOR = 0.32 [95% CI (0.12, 0.86)] and women who had no formal education, 68.4% [95% CI (0.12, 0.85)] less likely to develop PIH than women had primary and above educational status. Thus, the model was identified; gravidity, educational status, and previous history of pregnancy-induced hypertension were determinant factors for pregnancy-induced hypertension. Furthermore, Pregnancy-induced hypertension had an impact on inducing maternal complication, perinatal death and Intra-Uterine growth retardation/IUGR ( Table 5 ).

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https://doi.org/10.1371/journal.pone.0250548.t005

This study revealed that 21(30.4%) among cases and 21(15.2%) women in control groups had developed at least one complication following delivery. The finding is supported by the study conducted in India 54% among case and 9% from controls developed maternal complications [ 36 ]. Also, a study done by Kapil Dev revealed that among cases 24% of women developed at least one maternal complication, but there was no maternal complication in controls [ 37 ]. A lower proportion of maternal complication in this study could be due to living style and women in the study area had less history of medical complications.

The commonest maternal complications in this study were postpartum haemorrhage/PPH 13 (18.8%), which is higher than the study done in India [ 35 ]. The lower proportion reported from elsewhere might be a better management approach and health care setups in those facilities were more intensive and organized as compared to our study area.

This study showed that perinatal complications were more prevalent among controls (63.4%) as compared to cases (58.2%). The finding is supported by the study done by Aleem Arshad, only 1 and 13 low birth weight reported from cases and control, respectively [ 44 ]. In this study, neonatal death was the second leading outcome of PIH, 17.4% from cases and 5.7% controls deaths were reported. Concerning perinatal complications, this study reported that 15.6% IUGR from cases and 3.6% from control which was lower than a study conducted in India; 29% and 71% IUGR were reported from women who had developed PIH and normotensive, respectively [ 36 ]. The possible reason for the low proportion could be socio-demographic factors and women in our study area affected by low superimposed medical problems.

Out of the cases, group preeclampsia accounted for 58(84.1%) whereas eclampsia comprises 11(15.9%). A study was done in Harare, Zimbabwe reported the proportion of pre-eclampsia and eclampsia were 1.7% & 0.3% respectively [ 9 ], but the proportion was lower than a study conducted by Selemawit, 121 women developed Pre-eclampsia and 17 of them Eclampsia [ 45 ]. The difference might be due to early identification and alerting women during ANC visits which decrease the possible occurrences of preeclampsia and eclampsia. Other study carried in three south-west hospitals, Ethiopia and tertiary care hospital of Visakhapatnam, India reported in the prevalence of pre-eclampsia and eclampsia were 7.9%, 3% and 16%, 36% respectively among cases [ 36 , 46 ].

In this study gravidity has an association with PIH, women with gravidity 3 and above were 68% [95% CI (0.12, 0.86)], less likely to develop Pregnancy-induced hypertension as compared to their counterparts. This study is in-line with a study done in Darashe Special woreda [ 39 ] and Kombolicha, Ethiopia [ 41 ]. Whereas, the finding is in contrast with the study done in Addis Ababa, Ethiopia and Colombia; primigravida women were 2.7 times more likely to develop PIH than multigravida [ 24 ], and 36.9% of primigravida women among cases had developed PIH [ 47 ], the possible reason might be due to difference in assigning the reference group.

History of previous pregnancy-induced hypertension was significantly associated with PIH. In our study previous history of pregnancy-induced hypertension had 22 times increased odds of pregnancy-induced hypertension as compared to previous normotensive women. Out of the total interviewed women who had previous history of pregnancy-induced hypertension, 34.8% in cases and 2.9% in controls groups developed PIH in the current pregnancy. This finding is in-line with the studies done in Addis Ababa, Ethiopia and Karnataka, India. Women with a previous history of pregnancy-induced hypertension were 4 times more likely to develop PIH during current conception, which reported 28.95% women among cases and 10.9% among control had developed PIH in Karnataka, India. Women with a previous history of PIH were 58 times odds of developing PIH, out of the total interviewed cases 60% and controls 2.50% of women developed PIH during current pregnancy [ 36 ]. However, the finding of this study contradicts with the study done in Jaipur, India [ 40 ].

In this study, multivariable analysis revealed that previous history of medical illness had no statistical association with PIH, but studies conducted in Tigray, Kombolicha in Ethiopia, and Southern India reported that women with diabetic Mellitus were 5.4, 11 and 5 times more likely to develop PIH respectively [ 16 , 41 , 48 ]. The possible reason for this discrepancy could be that the number of women with a pre-existing medical problem in this study was fewer than those studies conducted elsewhere.

In addition to the maternal complication, this study singled-out that perinatal complications such as low birth weight, IUGR, and pre-term were higher in the cases than controls. Also, the study demonstrated that there was no association between PIH and birth weight which is in contrast with the study done in Zimbabwe where women with PIH were 3 times more likely to have a baby with low birth weight [ 9 ]. However, this study is in-line with a study done by Eskzyiaw [ 39 ]. Major perinatal complications reported in this study were LBW (31.1%), IUGR (6.9%) and preterm (6.8%).

Conclusion and recommendation

Pregnancy-induced hypertension yet has been seen as a burning issue, which provokes adverse health impact on mothers and their babies. In this study, both maternal and perinatal outcomes were significantly different in both groups (cases & control). Women with PIH were at higher risk for a maternal and perinatal adverse outcome as compared to normotensive women. Women with a previous history of PIH had increased risk of developing PIH whilst women who had ≥ 3 previous pregnancies and with informal education were less likely to develop pregnancy-induced hypertension.

Recommendation

For women diagnosed with a previous history of pregnancy-induced hypertension, health care providers should have taken especial attention and focused care to tackle the adverse effect of PIH on their current conception. Furthermore, concerning governing bodies and partners engaged in maternal service should have facilitated basic setups like on-job training on early screening skills and managements, tax-free transportation. When gravidity increased women may not caution as like the first conception so that clinical expertise gave attention to alerting women regarding early warning sign and improve health service delivery strategies. Principal governing bodies and concern partners should have facilitated maternal waiting room/village for better health, good perinatal and maternal outcome.

Supporting information

https://doi.org/10.1371/journal.pone.0250548.s001

https://doi.org/10.1371/journal.pone.0250548.s002

Acknowledgments

First, of all, I would like to Praise and give thanks to God for his grace and blessings over this work. Secondly, I would like to thanks Wachamo University research and community service and vice President Office and College of Health science and medicine for overall coordination since preparation to finalizing the research project. Finally, my greatest gratitude extends to my NEMMRH MCH departments professionals and Hossana town administration health office for giving the baseline data for this study.

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What is pregnancy-induced hypertension? Complications and risk factors

Pregnancy-induced hypertension can be referred to as unusually high blood pressure during gestation.

The condition is also known as gestational hypertension. Complications during pregnancy can be fatal, and high blood pressure during pregnancy increases the risk significantly.

Identifying the signs and symptoms during the early stages of pregnancy can help with the management of the condition. In this article, we bring you all about gestational hypertension along with a list of its symptoms.

Cause of pregnancy-induced hypertension

The exact cause of gestational hypertension is unknown, but it's believed that several underlying conditions lead to this problem. Risk factors associated with hypertension play a key role in the pathophysiology of the condition.

People with existing conditions are at a higher risk, as many medical conditions lead to increased blood pressure. If you are suffering from any medical condition, consult your doctor immediately.

Complications of pregnancy-induced hypertension

Complications depend on the type of condition and past medical history. Gestational hypertension can arise from prevailing chronic conditions as well.

High blood pressure before pregnancy can continue after the baby is born and can be considered chronic. Chronic hypertension can also lead to preeclampsia, which is discussed below.

Pregnancy-induced hypertension, which is observed in the later stages of pregnancy, can develop into preeclampsia. Regular observation is important to provide proper medical assistance, and the mother needs to visit the doctor more often.

Preeclampsia is a condition that's only found usually after 27 weeks of pregnancy. Elevated blood pressure readings and protein in urine can lead to the diagnosis. It can also affect the placenta, liver, kidneys, lungs or brain. Seizures (eclampsia) can occur when the condition affects the brain.

Pregnancy-induced hypertension risk factors

You may be more likely to experience gestational hypertension if you:

  • Are under the age of 20 or over the age of 40
  • Have suffered from gestational hypertension or preeclampsia in the past
  • Have a family history of pregnancy-induced hypertension
  • Have diabetes
  • Have kidney disease (both chronic and acute)
  • Are expecting twins, triplets or more babies

These risk factors must be kept in mind before planning a pregnancy, and precautions must be taken to prevent such conditions.

Pregnancy-induced hypertension symptoms

Some common signs and symptoms of gestational hypertension are:

  • Swelling (edema).
  • Unexplained weight gain.
  • Vision issues
  • Nausea or vomiting.
  • Less urine production.
  • Abdominal pain.

As many of these symptoms are common to many other conditions, it's important to get diagnosed by a doctor.

Your doctor might prescribe several blood tests to confirm any underlying conditions that might be the cause behind pregnancy-induced hypertension. Blood pressure should ideally be "120 over 80" (systolic blood pressure over diastolic blood pressure).

Urine tests can also be performed to check for proteins, which could give an insight into the severity of the condition. Tests related to liver, kidney and blood-clotting factors can also help with the diagnosis. A hypertension diet can also help manage the condition.

Pregnancy-induced hypertension treatment

Medications to manage blood pressure are usually prescribed by doctors. Monitoring blood pressure at home is essential for proper management.

In case of severe conditions, injections of blood pressure-lowering medication are required. Usually, hospitalization is necessary in such situations. Timely management and medical intervention can prevent any mishaps.

Indranil Biswas is a nutritionist and personal trainer with a diploma in dietetics and personal training with a specialization in sports nutrition and strength training.

What do you think of this story? Tell us in the comments section below.

What is pregnancy-induced hypertension? Complications and risk factors

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  • v.10(4); 2021 Apr

Prevalence of hypertension in pregnancy and its associated factors among women attending antenatal clinics in Bengaluru

1 ICMR-National Centre for Disease Informatics and Research, Bangalore, India

2 Indian Institute of Public Health Hyderabad, Bangalore Campus, Public Health of Foundation of India, Bangalore, India

Chandra S. Metgud

3 Department of Community Medicine, J.N. Medical College, Belgavi, Karnataka, India

Background:

Hypertension in pregnancy is a major challenge in antenatal practice due to its impact on obstetric and foetal outcomes.

To assess the prevalence of hypertension during pregnancy and its associated risk factors among pregnant women availing of antenatal care at public sector hospitals in Bengaluru, Southern India.

The sample frame included pregnant women who were attending the antenatal clinic at three public sector hospitals. The data were analyzed for 783 pregnant women who had completed their baseline visit over a period of 18 months (September 2017 to March 2019). The blood pressure was categorized based on the American College of Cardiology/American Heart Association 2017 guidelines.

Out of the 783 respondents who were examined, 13.9% were found to be hypertensive. The adjusted Odd's ratio was significantly higher for those who were employed outside the house and obese respondents. Other factors such as higher maternal age, lower socioeconomic status, pregnancy-related anxiety, prenatal depression, nulliparity appeared to increase the risk.

Conclusion:

Hypertension during pregnancy continues to be a matter of concern. Risk factor profiling of pregnant women is of utmost importance to identify those who may be likely to develop hypertensive disorders during pregnancy.

Introduction

Hypertension in pregnancy is a major challenge in antenatal practice due to its impact on obstetric and fetal outcomes. Hypertension plays a significant role in up to 15% of complications over the course of pregnancy and the postpartum period.[ 1 ] Hypertensive disorders of pregnancy encompass preexisting (or chronic) hypertension, gestational hypertension, preeclampsia, and eclampsia; accounting for an estimated prevalence of 5% to 10% in women belonging to the reproductive age group.[ 2 , 3 ] These are a significant contributor to maternal and perinatal morbidity and mortality and account for 30,000 maternal deaths annually at the global level and 10% to 15% of maternal deaths in low- and middle-income countries.[ 4 , 5 ] A multicenter study performed in four developing countries (India, Nigeria, Pakistan, and Mozambique) found that one out of every ten pregnant women had hypertension.[ 6 ]

Studies have found pregnancy-induced hypertension to be a significant independent risk factor for developing gestational diabetes mellitus.[ 7 ] The risk of developing cardiovascular diseases (CVD) in later life is reportedly higher among women with a history of raised blood pressure during pregnancy.[ 8 , 9 , 10 ] This has been attributed to the presence of common CVD risk factors such as type 2 diabetes, chronic hypertension, and raised blood lipids associated with rapid urbanization and changing lifestyles.[ 11 , 12 ] The incidence of hypertension during pregnancy is on the rise and is associated with an increased risk of fetal growth retardation and adverse birth outcome.[ 13 ] Studies from India report that hypertension during pregnancy may contribute to up to one-third of maternal deaths.[ 14 , 15 ] While blood pressure measurement is routinely monitored as a part of antenatal care, it is important to get a better understanding of the burden of hypertension during pregnancy and its associated risk factors. Primary care physicians are usually the first point of contact and it is essential for them to be sensitized concerning hypertension during pregnancy. Identification of modifiable risk factors would be vital for primary prevention of this condition and in avoiding adverse maternal and fetal outcomes.

Given this background, the present study aims to assess the prevalence of hypertension during pregnancy and its associated risk factors among pregnant women availing antenatal care at public sector hospitals in Bengaluru, Southern India.

Study setting and participants

The present study is part of a cohort study to assess the effect of prenatal exposure to maternal cortisol and psychological distress on infant development in Bengaluru.[ 16 ] The sample frame included pregnant women who were attending the antenatal clinic at three public sector hospitals: Jayanagar General Hospital, Kempu Cheluvarajamanni (KC) General Hospital, and H Siddaiah Referral Hospital. While Jayanagar General Hospital and K.C General Hospital are state government sub-district hospitals, H Siddaiah Referral Hospital is managed by the city's municipal corporation. The eligibility criteria for being selected for this study included pregnant women (i) who were between 18 to 40 years of age, (ii) having a gestational age of fewer than or equal to 24 weeks, and (iii) without any reported obstetric complication. Pregnant women who met the inclusion criteria and volunteered to participate in the study were recruited into the study. The data were analyzed for 783 pregnant women who had completed their baseline visit over a period of 18 months (September 2017 to March 2019).

Data collection and measurements

The participants were explained about the nature of the study, and a participant information sheet was given to them for further reference after which a written informed consent was obtained. The study questionnaire was digitally recorded through an App (CASCADE version 2.1.3) installed on an Android tablet. The questionnaire captured detailed information on socio-demographic data, social support, domestic violence, marital discord, medical history, obstetric history, and measures of depression and anxiety. Edinburg Postnatal Depression Scale was used to screen for depression in pregnant women. It is a 10-item self-report scale widely used for screening of prenatal depression.[ 17 ] Screening for anxiety during pregnancy was performed using the 10-item Pregnancy-Related Anxiety (PRA) Scale.[ 18 ] Social support was captured using the Multidimensional Scale of Perceived Social Support (MSPSS). It has 12 items to assess the subjective perceptions of support from family, friends, and “significant others” with scores ranging from 1 to 7.[ 19 ] The revised Kuppuswamy Scale was used to measure socioeconomic status.[ 20 ] Domestic violence and marital discord were identified using the Modified Conflict Tactics Scale and the Revised Dyadic Adjustment Scale, respectively.[ 21 ] The anthropometric measurements were recorded at the final stage of the interview using a standardized calibrated weighing scale for weight and a stadiometer for height for subsequent estimation of body mass index (BMI), expressed as weight in kilograms divided by height in meter square (kg/m[ 2 ]).

Blood pressure was recorded using the Omron HEM 7130 ®blood pressure monitor during each antenatal visit. The participant was asked to sit quietly and rest for 15 min with their legs uncrossed. The measurements were taken with the participant sitting upright with proper back support, and with the arm supported on a table or a surface at the level of the heart. Three readings were taken at an interval of 5 min, and the average of the three readings was taken as the final blood pressure reading. The blood pressure was categorized based on the American College of Cardiology/American Heart Association 2017 guidelines.[ 22 ] Blood Pressure in adults was categorized into four: 1) Normal (systolic blood pressure <120 mm Hg and diastolic <80 mm Hg); 2) Elevated (120–129 mm Hg systolic and <80 mm Hg diastolic); 3) Hypertension stage 1 (129–139 mm Hg systolic and 80–89 mm Hg diastolic); and 4) Hypertension stage 2 (≥140 mm Hg systolic and ≥90 mm Hg diastolic). The guidelines have recently been adopted by the American College of Obstetricians and Gynecologists (ACOG) for the treatment of chronic hypertension in pregnant women.[ 23 ]

Statistical analysis

The data wereretrieved from the App in Microsoft excel sheet format, cleaned, and exported to SPSS version 22. The exposure variables were categorized according to the data type and included. (i) Socio-demographic data: age, religion, educational status, socioeconomic status, occupation. (ii) Psychosocial variables: social support, marital discord, domestic violence, depression, anxiety, and unplanned pregnancy. (iii) Obstetric and medical variables: parity, history of hypertension, body mass index. Tobacco use was reported by only five women; hence, it was not included for analysis.

Descriptive statistics were used to present the socio-demographic characteristics of the study population. Bivariate analysis was performed to explore the association between independent and dependent variables and was expressed in terms of crude odds ratio with 95% confidence interval. The variables were dichotomized, and those which were found to be associated at a significance level ( P < 0.2) in the bivariate analysis were entered into a multivariate logistic regression model to calculate the adjusted odd's ratio and to eliminate the effects of confounding. Variables with a P value of < 0.05 in the multivariate analysis were considered to be significant in the study.

Ethical considerations

Ethical clearance was obtained from the Ethics Committee of the Indian Institute of Public Health Bangalore campus (IIPHHB/TRCIEC/118/2017) dated 15/3/2019. Participants were briefed about the study purpose, objectives, risk, and voluntary decision to decide their participation, and a written informed consent was obtained. Privacy and confidentiality of the individuals were strictly ensured throughout the study. Personal identification was masked using participant ID.

Socio-demographic characteristics of the study participants

The mean age of the study population was 23.6 ± 4.47 years, and the mean gestational age was 16.7 ± 4.4 weeks. The socio-demographic characteristics are shown in Table 1 . The majority (88.8%) of the study participants were of or less than 28 years of age and more than half of them were of Islamic faith and were parous. About 90 percent of the respondents were homemakers and over one-third of them had received education up to high school. Almost 43.9 percent of them belonged to the upper lower class and more than 50 percent were receiving high social support from family, friends, and significant others.

Socio-demographic characteristics of the study participants ( n =783)

Prevalence of hypertension

Out of the 783 respondents who were examined, 13.9% were found to be hypertensive [ Figure 1 ].

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Prevalence of hypertension among the pregnant women (n = 783)

Association of socio-demographic variables with hypertension

Among the socio-demographic variables, the risk of hypertension in pregnancy was observed to be 1.7 times higher among women above the age of 28 years. This finding was significant on bivariate analysis but not after adjustment of confounders. The women who were employed outside the home were twice as likely to suffer from hypertension when compared to the homemakers; this being significantly higher on multivariate analysis (COR = 2.000; 95% CI: 1.01–2.28, AOR = 1.481; 95% CI: 0.97–2.24) [ Table 2 ].

Bivariate and multivariate analysis of risk factor variables

Association of psychosocial variables with hypertension

The odds of hypertension was 1.3 times higher among women with moderate to low social support although this was significant only on bivariate analysis. Pregnancy-related anxiety was found to be a positive predictor of hypertension (COR = 1.519; 95% CI: 1.01–2.28, AOR = 1.481; 95% CI: 0.97–2.24). Women who were depressed were 1.2 times more likely to be hypertensive, but this likelihood was not significant [ Table 2 ].

Association of physiologic parameters with hypertension

While no significant association could be demonstrated between a history of hypertension, gravidity, and hypertension in the present pregnancy, it was observed that obese pregnant women were twice as likely to be hypertensive than nonobese women, with an AOR of 2.036 (95% CI 1.328–3.122) [ Table 2 ].

The present study examined the prevalence of hypertension in pregnancy and its associated factors using the American College of Cardiology/American Heart Association 2017 guidelines. The prevalence of hypertension in the present study was observed to be 13.9 percent. This happens to be exactly equal to the observed rate of 13.9% demonstrated by Ganguly and Begum in a hospital-based study in Dhaka, Bangladesh.[ 24 ] There appears to be a striking geographic variation in the prevalence of hypertension across different states of India. The prevalence found in our study is slightly lesser than the reported prevalence rate of 15.5% from a hospital-based study conducted in Kolkata[ 25 ] but much higher than that elicited from other similar settings: 7.49% in Indore,[ 26 ] 5.38% in Varanasi,[ 27 ] and 10.4% in Salem.[ 28 ] This could be attributed to the use of JNC VII report for classification of hypertension in other studies, which used higher cut off values of BP ≥140/90 mm Hg. Lower values of prevalence have also been recorded in community-based studies such as reported rates of 6.9% and 5.8% in rural settings of Haryana and Punjab,[ 29 , 30 ] respectively. The use of an expanded definition for hypertension as used in the present study may help to identify more women who would benefit from timely management.

The odds of hypertension were higher among women more than28 years of age although this was not statistically significant. Hypertension in pregnancy is known to be associated with advancing maternal age. This could be attributed to high levels of oxidative stress and low levels of nitric oxide that are associated with aging, which exerts an adverse influence on the relaxation of the endothelium.[ 31 ] Illiteracy has been reported to be an important risk factor for hypertension in pregnancy due to its relationship with early marriage and care-seeking behavior; however, no such observation was seen in the present study. We found that women who were employed outside the house were at a higher risk for hypertension. Other studies have also reported a similar association,[ 32 , 33 , 34 ] whereas some studies report that the risk is higher among homemakers.[ 35 ] Further research would be required to explain these differences as it may be determined by the nature and duration of work, whether done at home or outside.

Among the psychosocial variables, we could not establish any increase in risk with lower social support, unplanned pregnancy, and domestic violence. However, pregnancy-related anxiety appeared to be a positive predictor of hypertension. A plausible explanation is that stress during pregnancy is frequently associated with dysregulation of the hypothalamo pituitary adrenal (HPA) axis, resulting in a high endogenous cortisol level, which causes endothelial dysfunction.[ 36 , 37 ] Similarly, pregnant women who were depressed appeared to be at a higher risk of hypertension although this was statistically not significant. Thombre et al . in their study confirmed that pregnancy-related anxiety increased the risk of hypertension during pregnancy by 1.2 times even after adjusting for confounding variables.[ 38 ]

Although primi parity is implicated to be a risk factor for gestational hypertension,[ 39 , 40 , 41 ] we could not identify any such association on multivariate analysis. The association between primi parity and hypertension has been ascribed to an array of physiologic and immunologic pathways.[ 42 ] The risk of hypertension appeared to be more than twice as higher among obese pregnant women than nonobese and was significantly associated even after adjusting for confounders. This is synonymous with results from other studies from different countries.[ 43 , 44 , 45 ] The pathophysiologic mechanism, which accounts for the relationship between obesity and hypertension is the state of hyperinsulinemia induced by high body mass index, which causes endothelial dysfunction.[ 46 ] The risk of pre-eclampsia is also stated to be increased due to high levels of triglyceride and free fatty acids that are associated with obesity.[ 47 ]

The present study has helped to identify a few modifiable risk factors of hypertension during pregnancy, such as obesity, which conforms to those observed in other similar study settings. The adjusted odds ratio was significantly higher for those who were employed outside the house and obese respondents. Other factors such as higher maternal age, lower socioeconomic status, pregnancy-related anxiety, prenatal depression, nulliparity appeared to increase the risk. Risk factor profiling of pregnant women is of utmost importance to identify those who may be likely to develop hypertensive disorders during pregnancy. Many of these factors could be addressed during early pregnancy, which would go a long way in preventing morbid obstetric and fetal outcomes and also reduce the future risk of cardiovascular complications among women.

Study limitations

The settings for this study comprised urban public sector hospitals wherein antenatal care is mostly availed by pregnant women belonging to the lower- and middle-income groups. Therefore, the findings from this study cannot be extrapolated to pregnant women belonging to a higher socio-economic group due to differences in psychosocial factors and standard of living. As this study was conducted as a part of an ongoing cohort study, it was not possible to capture data and identify factors such as a family history of hypertension, hypertension in previous pregnancies, prepregnancy weight for measuring weight gain, diet, physical activity, and history of diabetes; as observed in other studies. By excluding respondents who had obstetric complications, we have focused on the nonobstetric risk factors of hypertension during pregnancy.

The results were generated out of an analysis of data recorded in the baseline visit done around 24 weeks of the cohort study; hence, the reported hypertension could not be segregated into categories of chronic hypertension, gestational hypertension, and preeclampsia/eclampsia.

The present study reports that hypertension during pregnancy is emerging as a major concern from a clinical and public health viewpoint, given that it could have serious short- and long-term consequences for maternal and offspring health. A substantial proportion of more than one-tenth of the pregnant women were found to be hypertensive in the present study. Primary care physicians have a critical role to play in the early identification and management of hypertension during early antenatal care.

Financial support and sponsorship

This project is funded by Welcome Trust DBT India Alliance (Clinical and Public Health Research Fellowship); grant number IA/CPHI/16/1/502634.

Conflicts of interest

There are no conflicts of interest.

Acknowledgements

The authors would like to extend thanks to the staff of the study hospitals and the women for participating and supporting them during data collection.

IMAGES

  1. Pregnancy Induced Hypertension Essay Example

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  2. (PDF) PHYSIOLOGICAL PARAMETERS IN PREGNANCY INDUCED HYPERTENSION

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  5. (PDF) Factors Related to Pregnancy Induced Hypertension

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COMMENTS

  1. A 21-Year-Old Pregnant Woman with Hypertension and Proteinuria

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  3. Pregnancy Induced Hypertension and Associated Factors among Women

    Prevalence of pregnancy induced hypertension: The prevalence of pregnancy induced hypertension among women attending delivery service in the three hospitals of this study was 33(7.9%). The mean of systolic blood pressure was 110.72±15.315 with range of 90 mmHg to 210 mmHg, and the mean of diastolic blood pressure was 72.71±13.093 with range ...

  4. Case 36-2006

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  5. Determinants of Pregnancy-Induced Hypertension among Mothers Attending

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  6. Pregnancy Induced Hypertension among Pregnant Women Delivering in a

    Pregnancy Induced Hypertension (PIH) is one of the commonest causes of both maternal 1 as well as neonatal mortality 2 and morbidity that develops as a result of pregnancy and generally regresses after delivery, affecting about 5-8 % of pregnant women, moreover 5-22% of pregnancies especially in developing countries. 3

  7. Pregnant women's experiences with the management of hypertensive

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  9. PDF Severe Hypertension in Pregnancy: Case Studies and Lessons Learned

    Start with fit Move on to accuracy THIS IS A NO SHAME GAME! Case 1 Lessons Learned Start with the fit Proper fitting cuff: width of bladder 40% of circumference and encircle 80% of arm Too small false elevation, too big falsely low (up to 40 mmHg variation in systolic BP) At rest at least 5 minutes Activity can increase systolic BP by 20 mm Hg

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    Hypertensive disorders represent one of the most common medical complications of pregnancy. 1,2 Based on a nationwide inpatient sample examining more than 36 million deliveries in the United States, the prevalence of associated hypertensive disorders increased from 67.2 per 1,000 deliveries in 1998 to 83.4 per 1,000 deliveries in 2006. 3 Pregnancy-induced hypertension (also referred to as ...

  11. Case Study: Hypertension in Pregnancy

    My patient Madam Siti a 31 year old Indonesian maid Gravida 3 para 2 at 38 weeks and 1day of Period of Amenorrhoea (POA) was admitted to the ward for blood pressure stabilization and induction of labour (IOL). History of Presenting Illness She was referred from antenatal clinic during follow up in PPUKM on 29/11/2010.

  12. Determinants of pregnancy-induced hypertension on maternal and foetal

    PMC8115896 10.1371/journal.pone.0250548 Globally, 292,982 women die due to the complications of pregnancy and childbirth per year, out of those deaths 85% occurs in Sub Saharan Africa. In Ethiopia, pre-eclampsia accounts for 11% of direct maternal deaths.

  13. Determinants of pregnancy-induced hypertension on maternal and foetal

    Women with a previous history of pregnancy-induced hypertension had increased risk of developing pregnancy-induced hypertension, whilst ≥ 3 previous pregnancies and informal educational status decrease odds of developing pregnancy-induced hypertension. Go to: Introduction

  14. Effects of a Case Management Program for Women With Pregnancy-Induced

    Background: Pregnancy-induced hypertension (PIH) is a leading cause of maternal and fetal morbidity and mortality. Although case management programs have been proposed to improve maternal and fetal outcomes in high-risk pregnancies, limited data are available regarding the effect of case management on women with PIH.

  15. Hypertension in pregnancy: A case discussion

    E. Bors, J.D. French, Management of paroxysmal hypertension following injuries to cervical and upper thoracic segments of the spinal cord AMA Arch Surg 64: (1952) 803-812 27. M. Nath, J.M. Vivian, W.B. Cherny, Autonomie hyperreflexia in pregnancy and labor: a case report Am J Obstet Gynecol 134: (1979) 390-392 28.

  16. Determinants of Pregnancy-Induced Hypertension among Mothers ...

    Background . It has been estimated that approximately 14% of maternal death has resulted due to pregnancy-induced hypertension. Evidence also suggests that pregnancy-induced hypertension may result in adverse maternal and child outcomes. The aim of this study was to assess the determinants of pregnancy-induced hypertension among mothers attending antenatal and delivery services at public ...

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  18. Hypertensive disorders of pregnancy: Case definitions & guidelines for

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    Pregnancy Induced Hypertension is a form of high blood pressure in pregnancy. It occurs in about 5 percent to 8 percent of all pregnancies. It is a condition in which vasospasm occurs during pregnancy in both small and large arteries. With high blood pressure, there is an increase in the resistance of blood vessels.

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    Sample size. The sample size for this study was computed based on the comparison of proportion for case control study by using Epi-info version 7 for windows. ... Being multigravida and age during current pregnancy between 25-30 years which have a significant association with pregnancy-induced hypertension with case to control ratio 1:2 and ...

  21. Case Study: Treating Chronic Hypertension in Pregnancy

    Article Chronic hypertension during pregnancy increases the risk of poor pregnancy and birth outcomes. Case: A 35-year-old female presents to clinic. She is actively trying for pregnancy and already stopped her birth control. Her medical history includes a 5-year history of hypertension treated with an ACE inhibitor.

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    Pregnancy-induced hypertension (PIH) is a leading cause of maternal and fetal morbidity and mortality. Although case management programs have been proposed to improve maternal and fetal outcomes in high-risk pregnancies, limited data are available regarding the effect of case management on women with PIH.

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    Introduction. Hypertension in pregnancy is a major challenge in antenatal practice due to its impact on obstetric and fetal outcomes. Hypertension plays a significant role in up to 15% of complications over the course of pregnancy and the postpartum period.[] Hypertensive disorders of pregnancy encompass preexisting (or chronic) hypertension, gestational hypertension, preeclampsia, and ...