Management of hypertensive disorders of pregnancy in two Australian tertiary care maternity hospitals.

Background: Hypertensive disorders of pregnancy (HDP) are common obstetric medical problems. Compliance with clinical guidelines and evidence from major trials has the potential to translate to significantly improve maternal and perinatal outcomes. The aims of this study were to prospectively review management of HDP in an Australian cohort in the context of the Society of Obstetric Medicine of Australian and New Zealand (SOMANZ) guidelines and current evidence in published literature regarding management controversies. Methods: The management of 100 pregnant women with HDP and prescription for antihypertensive medication at two tertiary obstetric centres was prospectively reviewed in 2013. Compliance with SOMANZ guidelines, uptake of findings from the HYPITAT trial and the Control of Hypertension In Pregnancy Study (CHIPS) trial were assessed. Results: Sixty-eight women had chronic hypertension, while 32 had gestational hypertension. Management of HDP was mostly consistent with current SOMANZ guidelines and evidence from CHIPS and HYPITAT. Conclusion: Clinicians were practising according to the current SOMANZ guidelines, indicating vigilance on behalf of the treating team.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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.

'I wish my body was stronger': A qualitative study of attitudes and behaviours regarding treatment of hypertensive disorders of pregnancy.

OBJECTIVES: To investigate pregnant women's attitudes and behaviours towards hypertensive disorders of pregnancy and their treatment. METHODS: Face-to-face, in-depth interviews were undertaken with 27 pregnant women diagnosed with and being treated for hypertensive disorders of pregnancy to investigate attitudes and behaviours regarding the conditions and their treatment. Written consent was obtained individually from each participant, and the interviews ranged from 16 to 54 minutes. Data collection was continued until thematic saturation was reached. Thematic analysis was employed to interpret the data. RESULTS: Four major themes emerged around beliefs and behaviours of pregnant women regarding treatment of their hypertension: understanding of hypertensive disorders of pregnancy and their implications, risks versus benefits of antihypertensive medication during pregnancy, trust in medical professionals and adherence to medication. The women's level of understanding of hypertensive disorders of pregnancy and their implications determined whether they were able to make informed decisions about their treatment. Prior experiences and concern for preservation of the pregnancy played major roles in the perception of the risk/benefit balance of using antihypertensive medication during pregnancy. The degree of trust in the treating medical professionals varied according to the perception of their confidence and knowledge. CONCLUSIONS: Sound understanding of the condition, a positive risk/benefit balance regarding antihypertensive medication use during pregnancy, and trust in medical professionals contributed to adherence to medication. Good communication with healthcare professionals is important to achieve optimal treatment.

Adherence to anti-hypertensive medication in pregnancy.

OBJECTIVES: To assess adherence to anti-hypertensive medication by pregnant women and to identify the factors associated with adherence or lack thereof. STUDY DESIGN: Observational study in 100 pregnant women with either chronic hypertension or gestational hypertension who were being treated with at least one anti-hypertensive medication and attending antenatal clinics at one of two maternity hospitals. In-depth interviews were conducted with a subset of 27 women from the same group. Quotes from interview transcripts were used to illustrate the quantitative results. MAIN OUTCOME MEASURES: BP control, self-reported adherence, complexity of medication regimen. RESULTS: Participants (mean age 33 [±4.9] years; mean gestation 29 (±7) weeks) had a median blood pressure (BP) of 130/80 mmHg (IQR: 16/15). Sixty-five women had chronic hypertension, of whom 13 were diagnosed during pregnancy, before 20 weeks gestation. Thirty-five women had gestational hypertension. Ninety-two per cent of participants had sub-optimal adherence. There were no significant differences in adherence scores between participants with chronic hypertension and their counterparts. The main contributors to sub-optimal adherence were intentionally putting up with medical problems before taking any action, confusion about the medication, and making changes to the recommended medication regimen to suit lifestyle. CONCLUSIONS: Nine out of ten pregnant women using anti-hypertensives self-reported some degree of suboptimal adherence, intentionally and/or unintentionally. Health professionals, including pharmacists, general practitioners and obstetricians, have a role in promoting optimal medication adherence.

Management of pregnancies complicated by hypertensive disorders of pregnancy: Could we do better?

BACKGROUND: Hypertensive disorders are among the most common medical problems in pregnancy. Compliance with clinical practice guidelines has potential to translate to significant maternal and perinatal health benefits. AIMS: To evaluate compliance with Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) clinical guidelines for management of hypertension during pregnancy. METHODS: Inclusion criteria: women with hypertension in pregnancy who gave birth at a tertiary obstetric centre in 2010. Compliance with SOMANZ guidelines was assessed, as well as uptake of findings from the 'Induction of labour versus expectant monitoring for mild gestational hypertension/pre-eclampsia after 36 weeks' gestation' (HYPITAT) trial. RESULTS: Of 5624 women, 516 (9.2%) were identified with hypertension (49 chronic hypertension (CH); 457 gestational hypertension (GH) or pre-eclampsia (PE)). Thresholds to diagnose hypertension and initiate anti-hypertensive treatment were consistent with SOMANZ recommendations. Among women with CH, only 12.2% were prescribed aspirin prior to 16 weeks as PE prophylaxis. Of women with PE, 37 (18.6%) had known risk factors for development of PE at the initial visit yet only nine (24.3%) received aspirin. Of the 244 women who met HYPITAT inclusion criteria at 36 weeks, 174 (77.7%) were managed expectantly; nine (5.2%) developed severe adverse outcomes. CONCLUSION: Current management guidelines for hypertension treatment were generally followed, although aspirin prophylaxis was frequently overlooked, resulting in up to 19 excess PE cases. Uptake of recommendations from the HYPITAT trial was low; however, severe complications were fewer than expected. Overall, this suggests that clinicians appropriately weigh up the likely maternal risk compared to infant benefits of deferred delivery in each case, a key recommendation of HYPITAT-II.