Optimising the monitoring and management of raised blood pressure during and after pregnancy

Aims, Objectives and Research Questions The overall aim of this programme of work is to evaluated whether self-monitoring of BP can improve the detection of raised BP during pregnancy, whether it is feasible for use in the titration of antihypertensive medication in pregnancy hypertension and whether women with raised BP in pregnancy can accurately test their urine for proteinuria. Linked qualitative and economic components assess patient and professional experiences of self-monitoring and responses to it along with cost effectiveness within the trial and in the longer term. The key research questions are: WS1: Development What are the best self-monitoring interventions to use? How can self-monitoring of BP and urine best integrate into current antenatal care pathways? WS2: Self-monitoring to detect raised BP in pregnancy What is current practice in BP self-monitoring in pregnancy? Can BP self-monitoring improve the detection of BP during pregnancy? How is BP self-monitoring in pregnancy implemented in daily life and routine clinical practice? Is BP self-monitoring in pregnancy cost-effective? WS3: BP self-monitoring during and after pregnancy for detection of hypertension and antihypertensives titration Is titration of antihypertensive medication during and after pregnancy using self-monitoring feasible? What is the participant and professional experience of such monitoring and titration? WS4: Self-monitoring of urinary protein in hypertensive pregnancy Can pregnant women with hypertension accurately self-monitor for proteinuria and could this detect pre-eclampsia earlier than usual care? Is self-monitoring of urine practical and acceptable to hypertensive pregnant women, their midwives and obstetricians? WS5: Modelling of the potential long term costs and consequences Is self-monitoring of blood pressure and protein in hypertensive pregnancy potentially cost-effective and what are the key parameters affecting this? Background and rationale Raised BP affects 10% of pregnancies worldwide of which around half develop pre-eclampsia – hypertension plus proteinuria - a leading cause of maternal and perinatal morbidity and mortality. Early detection and subsequent management of pregnancy hypertension is therefore important and could be improved through self-monitoring whilst empowering women and allowing reduced antenatal visits. Our systematic review has shown that little evidence is currently available to guide the utilisation of self-monitoring. Feasibility work by ourselves in Oxford and Birmingham including 201 women has shown that self-monitoring of BP and urine in pregnancy has potential and is well tolerated by women. The proposed programme is organised in five work streams (WS). Research plan WS1 will fine tune our already developed interventions, finalise them with our patient participant groups and through focus groups with professionals and ensure that they can be integrated into usual care. WS2 will test self-monitoring of hypertension in women at higher risk of hypertension in pregnancy as a screening tool. 2268 women will be individually randomised to either usual care or self-monitoring at 20 weeks gestation and followed up until delivery. The primary outcome will be time to first detection of raised clinic BP. Process evaluation will assess both quantitative (intervention fidelity for women and the professionals) and qualitative (patient and professional experiences of self-monitoring including ethnographic observation) aspects. Economic analyses will assess cost effectiveness. WS3 will evaluate the feasibility of using self-monitoring of BP to guide the titration of antihypertensive treatment both during and immediately after pregnancy. 160 pregnant women (80 with gestational hypertension and 80 with chronic hypertension) will be randomised to either self-monitoring of BP or usual care and followed up until six weeks postpartum. Linked process evaluation wil