Routine monitoring for pre-eclampsia during pregnancy
Some women we talked to were offered extra monitoring because they had possible ‘risk factors’ for pre-eclampsia. Extra monitoring often meant being seen more frequently than the standard ‘routine’ antenatal appointments and being seen by different health professionals instead of, or in addition to, the ‘standard’ antenatal care team of GPs and/or midwives. Ruth X had “consultant care” with her second baby because she had developed gestational diabetes and had pre-eclampsia in her first pregnancy. Because Philippa had pre-eclampsia in her first pregnancy, she saw her midwife fortnightly and had regular appointments with a consultant during her second. This extra care made her feel “really well looked after” and “added to me being calmer”. However, not all women found the extra monitoring helpful. Protein in urine
Samples of urine are regularly checked for protein (proteinuria). Normally, when the kidneys are working well, protein is filtered out of the blood. Pre-eclampsia can cause damage to the kidneys which make them less effective at removing the protein, although there can be other causes too for leaking protein into the urine.
Testing for proteinuria involves using a dipstick to test the urine, which changes colour depending on the result. If the dipstick shows there is protein in the urine, then more detailed tests may be carried out. Other tests can give more detailed information, for example by indicating how much proteinuria is present. Proteinuria was sometimes measured as a single positive number: 1+, 2+, 3+ or 4+ based on ranges of grams of protein in the urine.
Blood tests were often taken at antenatal appointments. There are lots of different tests that can be run on blood samples, including one to check the platelet count. Platelets are important because they help the blood to clot and to stop bleeding. Low levels of platelets mean that the woman is at risk of serious bleeding. The results of a platelet count were usually given as a number in the thousands per microliter of blood.
Some women remembered having blood tests taken. Lyndsey was admitted to hospital with high blood pressure and protein in her urine, but she doesn’t remember it being explained why low platelets levels in her blood would be an important result. Paige remembered having lots of blood tests, her arms were full of bruises “where they were just sticking stuff in, pulling blood out”. Blood pressure
Blood pressure measures the strength that blood is moved around a person’s body through their arteries. Blood pressure is usually measured using a monitor connected to an arm cuff which automatically inflates or by a trained health professional using equipment such as a hand pump and stethoscope. Blood pressure is recorded in millimetres of mercury (mmHg) and readings are made up of two numbers: systolic pressure (the pressure when blood is being pushed out by the heart) and diastolic pressure (the pressure when the heart rests between beats). For example, if a person’s systolic pressure was 120mmHg and their diastolic pressure was 80mmHg then their blood pressure reading would be 120/80.
Blood pressure often changes during pregnancy. Usually, blood pressure goes down for the first couple of months and then, around the half-way point (about 4-5 months), blood pressure tends to rise again back up to similar pre-pregnancy levels. However, for some, blood pressure doesn’t follow this pattern. Instead, their blood pressure may rise up higher than is ‘normal’ or earlier on in their pregnancies. This can indicate a high blood pressure problem, such as pregnancy-induced hypertension or pre-eclampsia. Regular checks track how a woman’s blood pressure is changing and pick up signs of what may be happening or likely to happen later on in her pregnancy.
- Dr Rehan-Uddin Khan has a special interest in multi-professional health education, simulation training and human factors in Women’s Health.
Over the course of a pregnancy, blood pressure does not typically stay absolutely steady. It usually starts at a certain level. During the middle of the pregnancy, it would usually slightly and gently fall. And towards the end of the pregnancy, the blood pressure will slightly and gently rise roughly back to the level where it was at the start. However, we have to track these blood pressure changes by checking blood pressure at each routine check because this is the method by which we work out if, instead of these normal changes, a woman is starting to develop hypertension in pregnancy or pre-eclampsia.
When we measure blood pressure, there are two separate numbers. The first is called systolic blood pressure and the second is call diastolic blood pressure. The reason you have to take two separate measurements is because, over the course of one heartbeat, how high or low the pressure is inside a blood vessel changes. When the blood has been forced out from the chambers of the heart into the large blood vessels of the body, the blood pressure initially is relatively high. When the heart muscle subsequently relaxes, so that the chamber can fill up with more blood to be pushed out over the next cycle, the pressure is relatively low. So we look at both numbers because both are important and sometimes we look at the difference between the two.
Some women showed early signs that they might develop high blood pressure problems in pregnancy. Their doctors usually offered extra monitoring to keep an eye on it. At her booking appointment at 10 weeks, Samantha Y was told she had high blood pressure. She saw a doctor or midwife every two weeks so it could be monitored closely. However, others didn’t feel they were monitored enough. Tracey felt that “you’re left to your own devices”. If a pregnant woman is worried something might be wrong, she can ask her doctors and/or midwives to do extra checks. Symptoms to look out for include rising blood pressure, headaches and swelling. Kat was taking part in the BuMP study; she was pregnant with twins and contacted her midwife when some of her self-monitored blood pressure readings were high. The midwife ran some tests to rule out any problems and Kat said this was “really good reassurance”.
However, some women felt they had been dismissed by health professionals. Their message to other pregnant women was to be assertive and determined in asking for medical help. Munirah said, “go to your doctor and don’t take ‘no’ for an answer”. If it turns out that everything is fine, then the test results can be reassuring; if a problem is found, doctors can take steps sooner to make the pregnancy safer. High blood pressure problems can still continue several weeks after birth. So blood pressure is checked at postnatal appointments. Some women had felt unwell and either contacted a health professional or mentioned it at a check-up appointment for their baby.