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DOI: 10.1111/tog.




The Obstetrician & Gynaecologist

Blood pressure measurement in pregnancy
Hannah L Nathan MBBS BSc DFSRH,a Kate Duhig MBBS BSc MRCP,b Natasha L Hezelgrave
Lucy C Chappell MBBS PhD,c Andrew H Shennan MBBS MD FRCOGd,*




Clinical Research Fellow, Women’s Health Academic Centre, King’s College London, 10th floor, North Wing, St Thomas’ Hospital,
London SE1 7EH, UK
Academic Clinical Fellow, Women’s Health Academic Centre, King’s College London, 10th floor, North Wing, St Thomas’ Hospital,
London SE1 7EH, UK
Clinical Senior Lecturer, Women’s Health Academic Centre, King’s College London, 10th floor, North Wing, St Thomas’ Hospital,
London SE1 7EH, UK
Professor of Obstetrics, Women’s Health Academic Centre, King’s College London, 10th floor, North Wing, St Thomas’ Hospital,
London SE1 7EH, UK
*Correspondence: Andrew H Shennan. Email:

Accepted on 8 January 2015

Key content

Learning objectives  

Accurate blood pressure (BP) measurement is fundamental to early
diagnosis of hypertensive disorders in pregnancy. 
Poor auscultatory technique and lack of training leads to
inaccuracies in BP measurement using sphygmomanometry with
mercury and aneroid devices. 
Automated devices limit user error but require validation of
accuracy because they tend to underestimate BP
in pre-eclampsia. 
Systolic hypertension may better predict risk of adverse outcome
(such as haemorrhagic stroke) than diastolic hypertension. 
Ambulatory/self-monitoring increases the number of
representative readings available on which to base management,
limiting unnecessary intervention. 
Detection of hypotension in pregnancy is crucial to the diagnosis
of shock secondary to haemorrhage and sepsis. 

To learn how to obtain accurate BP measurements in pregnancy.
To understand the significance of hypertension in pregnancy.

Ethical issues 

A large proportion of maternal deaths are associated with
substandard care, often related to poor recognition of severity of
hypertension or shock and need for treatment. 
Lack of cheap, accurate, easy-to-use BP devices in low- and
middle-income countries, where risk of maternal and perinatal
mortality and morbidity secondary to pre-eclampsia and shock is
highest, continues to be a challenge.
Keywords: blood pressure measurement / diagnosis /

hypertension / pre-eclampsia

Please cite this paper as: Nathan HL, Duhig K, Hezelgrave NL, Chappell LC, Shennan AH. Blood pressure measurement in pregnancy. The Obstetrician &
Gynaecologist 2015;17:91–8.

Hypertensive disorders in pregnancy, which include preeclampsia,
hypertension, complicate 2–8% of pregnancies and confer
risk to the health of mother and fetus.1 Pre-eclampsia is one
of the three leading causes of maternal death in the UK and
can result in substantial maternal morbidity, including
intracranial haemorrhage, HELLP (haemolysis, elevated
liver enzymes and low platelet count) syndrome and
disseminated intravascular coagulation.2 In 2010 an
estimated 287 000 maternal deaths occurred globally, 99%
of which occurred in low- and middle-income countries
(LMICs). Approximately 14% of these deaths were thought
to be related to hypertensive disorders in pregnancy,3

ª 2015 Royal College of Obstetricians and Gynaecologists

although this figure may be higher when the contribution
of hypertensive disorders in pregnancy to other causes of
mortality (such as postpartum haemorrhage) is considered.
Pre-eclampsia also contributes to one-fifth of all preterm
births globally (and is the leading cause of iatrogenic preterm
birth) and one-quarter of stillbirths and neonatal deaths
in LMICs.1
Accurate measurement of blood pressure (BP) is crucial to
the diagnosis and management of hypertensive disorders in
pregnancy. BP monitoring is the most important, and
frequent, screening test in the antenatal period and is
undertaken by healthcare assistants, midwives, general
practitioners and obstetricians on a daily basis. Accuracy of
BP measurement impacts on maternal and perinatal clinical
outcomes, highlighted in the 2006–2008 UK Confidential


Considering these findings and that K5 is better reflective of intra-arterial pressure and is far more reproducible.Pregnancy BP measurement Enquiries into Maternal Deaths report. However. pregnancy-related sepsis and unsafe termination of pregnancy are major contributors to approximately 46% of maternal deaths worldwide and all can present with signs and symptoms of shock.6 A randomised controlled trial published in The Lancet in 1998.3 According to the Confidential Enquiries report. antihypertensive treatment and timing of delivery. in order to prevent maternal and perinatal morbidity and mortality. both in the UK and worldwide. Despite these clear recommendations. K5) should be used to classify diastolic BP in pregnancy. in clinical practice BP measurement is often not performed correctly. clinicians are gradually moving away from such sphygmomanometers because of health and environmental concerns regarding the use of mercury in clinical settings.10 Despite recommendations to record BP to the nearest 2 mmHg.9. As of 2014. including choice of device. simultaneous systolic and diastolic hypertension. mercury sphygmomanometers are banned and can no longer be purchased in Europe because of environmental concerns.9 Observational studies assessing the calibration of BP devices used in clinical practice demonstrated that 20–25% of devices used in hospital and clinic settings had unacceptable calibration errors. It was argued that K4 was more appropriate considering the unique haemodynamics of pregnancy and because it was thought that K5 could often extend to or near zero (since shown to be very rare). the frequency of severe systolic hypertension. Some non-automated BP devices require regular calibration to ensure a leak rate (loss of air pressure) within 4 mmHg/minute and a pressure scale accurate to within 3 mmHg for any part of the pressure range.7 comparing outcome in hypertensive disorders in pregnancy managed according to either K4 or K5. Obstetric haemorrhage. As well as detecting hypertension. It also discusses the evidence-based hypertension BP thresholds at which there is increased risk of morbidity and mortality in pregnancy. regardless of setting. Auscultatory technique The National Institute for Health and Care Excellence (NICE)5 Antenatal Care guidance recommends BP measurement at every antenatal visit and outlines the steps involved in BP measurement using the auscultatory technique. and the importance of prompt medical intervention.8 the use of K5 to classify diastolic BP was recommended and has since been included in the NICE5 Antenatal Care guidelines. K4) or Korotkoff phase V (disappearance of sound. Korotkoff IV versus V Up until the late 1990s there was debate as to whether Korotkoff phase IV (muffling of sound. demonstrated that an episode of severe hypertension was more likely in women in the K4 group. midwives and other healthcare workers. initial inflation of the cuff 20–30 mmHg above the palpable systolic BP. 92 because of inadequate training and equipment. This includes use of the correct-sized cuff. Thus. BP devices are also essential for the detection of acute haemodynamic compromise and management of shock in pregnancy. deflation at a rate of 2 mmHg per second. as well as the role of vital sign monitoring in women at risk of shock. For example. recording BP to the nearest 2 mmHg and use of Korotkoff phase V to indicate diastolic BP. deflating the cuff too fast will result in underestimation of the systolic BP and overestimation of the diastolic BP.11 A study assessing BP values in women seen at antenatal clinic showed that 78% of readings obtained by clinicians ended in a zero. This review considers the importance of accuracy of BP measurement. and maternal and fetal adverse clinical outcome did not differ between the two groups. guiding diagnosis. time constraints or lack of awareness of the importance of BP monitoring as a screening and diagnostic test. admission. as well as the assessment of haemodynamic shock in pregnancy. a questionnaire-based study reported that only 10% of midwives and obstetricians recorded BP to the nearest 2 mmHg.4 the majority of maternal deaths could have been avoided if early warning signs of impending collapse had been recognised and acted on earlier. leading to inaccurate readings. mainly because diastolic hypertension was more likely to be recorded. the ability to measure BP accurately is an indispensible skill for obstetricians. Accuracy of BP measurement in pregnancy BP measurement is a key part of the assessment of hypertensive disorders in pregnancy.12 This user preference to round off BP values to a zero or five is referred to as ª 2015 Royal College of Obstetricians and Gynaecologists . with 23% recording BP to the nearest 10 mmHg. Although auscultation using mercury sphygmomanometry has been the gold standard of BP measurement in the past. secondary to obstetric haemorrhage or sepsis. It is therefore important that all healthcare providers are aware of the issues surrounding accuracy of BP measurement in pregnancy.4 which found that the most common reason for substandard care in deaths secondary to pre-eclampsia/eclampsia was failure to recognise and treat hypertension. Sources of error associated with auscultatory technique BP measurement using the auscultatory technique relies on accurate transmission and interpretation of Korotkoff sounds. technique and common errors.

where the observer adjusts the BP reading to avoid thresholds that entail making a diagnosis or requiring intervention. which rely on detecting changes in the amplitude of the intra-arterial oscillometric waveforms produced during cuff deflation to determine BP. the obvious benefit over auscultation (mercury sphygmomanometry and Box 1. community healthcare providers caring for women antenatally may have had limited training in BP measurement. only a small number have been evaluated and even fewer have passed validation. aneroid devices require more frequent maintenance and calibration than mercury sphygmomanometers. BP can be underestimated. BP can be overestimated.14 Although a seemingly small difference from the true reading.19 This is thought to be due to specific pathological changes of pre-eclampsia. likely because of the haemodynamic changes of pregnancy. which includes pre-eclampsia (Box 1). If the appropriately sized cuff is not available. Aneroid devices Aneroid devices remove the need to use mercury in clinical settings. Appropriate BP cuff size To ensure accuracy it is important to consider the size of BP cuff used.html#ClinTable aneroid) is that inaccuracies secondary to observer error are limited and BP measurement is simpler.16 Oscillometry: an alternative to the auscultatory technique The auscultatory technique for measuring BP requires skill and training. their accuracy can be assumed to be similar to mercury devices_1_clinical. if a standard cuff is used on a woman with an arm circumference of more than 32 cm. In these settings. there has been a shift towards the use of automated BP devices. that is.17. This concept can extend to threshold avoidance. In a clinical setting large cuffs are often less readily available than standard cuffs. which may affect the amplitude and detection of the oscillometric waveform. For those automated devices that are validated for use in pregnancy (including pre-eclampsia).18 Despite this recommendation. In recent years. automated devices may be a more practical alternative. Automated devices validated for use in pregnancy (including pre-eclampsia)          OMRON MIT Elite OMRON MIT OMRON Hem 705CP OMRON M7 Microlife WatchBP Home Microlife BP 3BTO-A Microlife BP 3AS1-2 Welch Allyn Spot Vital Signs Dinamap ProCare 400 http://www. and is therefore prone to observer error. the British Hypertension Society and a number of international organisations have recommended that automated devices are independently validated according to a recognised protocol to ensure accuracy (for example. However. Likewise. there are issues regarding cost.21 Conversely. The issue of accuracy is even more important for those devices used in pregnancy. resulting in false classification of normotension in these high-risk women.22 It is therefore important that a variety of cuffs are available in 93 .dableducational.20 Separate validation in pregnancy (including pre-eclampsia) is therefore recommended but only a small number of devices have passed validation for use in pregnancy. as shown in an observational study evaluating the accuracy of aneroid devices used clinically. particularly as obesity is a risk factor for pre-eclampsia and therefore those with a large arm circumference (33 cm or above) are at higher risk of developing pre-eclampsia. Furthermore. a systematic underestimation of BP by 3 mmHg would lead to one-quarter of patients with hypertension being falsely classified as normotensive. A survey of BP devices used by UK general practitioners showed that only 50% of devices had been serviced within 1 year and 24% had never been serviced. if a large cuff is used on a woman with a normal arm circumference.Nathan et al. the Association for the Advancement of Medical Instrumentation criteria. In LMICs. The Royal College of Obstetricians and Gynaecologists (RCOG). this is a source of error more commonly associated with auscultation. compared with a calibrated mercury sphygmomanometer. powering and maintenance of these devices. British Hypertension Society and International protocols).15 As long as aneroid devices are regularly maintained and calibrated.13 increasing the chance of error. including decreased arterial vascular compliance and increased interstitial oedema. Again. terminal digit preference and is a source of error associated with auscultation. of the hundreds of commercially available automated devices. far more than the mercury and automated devices. an observational study of devices used in UK general practices demonstrated that 53% of aneroid devices were reading in error by more than 3 mmHg. Observer bias refers to the user adjusting the BP reading to what is preferred or what it was preconceived to be. The majority of devices validated specifically in pregnant populations fail the protocol ª 2015 Royal College of Obstetricians and Gynaecologists requirements. A particular concern is that automated devices tend to underestimate BP in women with pre-eclampsia. but the inherent errors associated with sphygmomanometry and the use of Korotkoff sounds with auscultation remain. although this error is much less.

avoidable maternal and perinatal mortality and morbidity can result.05) for every mmHg increase in highest recorded systolic BP. A 2013 clinical review29 summarises the evidence for treatment options for postpartum hypertension and provides a flow diagram with management pathways.23 Research has demonstrated that women with an incremental rise (for example. the BP thresholds that indicate the need for treatment are less clearly defined. this is largely based on expert opinion. obstetricians use BP thresholds recommended by national guidelines to aid in management decision making.03. maternal and perinatal mortality and morbidity can again result. A landmark (yet small) retrospective cohort study of 28 women who sustained strokes in association with severe pre-eclampsia or eclampsia showed that all women had a systolic BP of more than 155 mmHg immediately before the stroke. The NICE guidance23 recommends initiating treatment at the same thresholds as for during the antenatal and intrapartum period. overcuffing (using a cuff that is too large for the arm circumference) is better than undercuffing (using a cuff that is too small for the arm circumference). rather than direct evidence. defined as the presence of neurological symptoms and signs.08. 95% CI 1.23 The 2010 NICE guidelines also recommend immediate treatment if diastolic BP is at least 100 mmHg. and severe hypertension as diastolic BP of 110 mmHg or above and/or systolic BP of 160 mmHg or above. a 2012 nested 94 case–control study investigating potential factors associated with antenatal stroke demonstrated that after adjustment for age. No role for isolated incremental rise in BP The use of an isolated incremental rise in BP to define hypertension in pregnancy is now not recommended in the guidelines. together with radiological findings of vasogenic cerebral oedema.23 However. Evidence-based hypertension thresholds Obstetricians use BP values to guide management in women with hypertensive disorders in pregnancy. However. and support the 2010 NICE guidelines recommending immediate treatment if systolic BP is 150 mmHg or above.23 BP thresholds for treating postpartum hypertension A 2005 Cochrane review on the management of postpartum hypertension28 demonstrated insufficient evidence to form robust recommendations on the thresholds for treatment. Although these definitions are concise and widely adopted. 30 mmHg systolic BP/ 15 mmHg) from booking whose BP remained under the threshold of 140/90 mmHg had normal pregnancy outcomes. an international multicentre randomised controlled trial on ª 2015 Royal College of Obstetricians and Gynaecologists . Similarly. If these thresholds are not supported by adequate evidence. The review concluded that it remains unclear whether treatment of mild-to-moderate hypertension is worthwhile.30 Future research to improve evidence base In response to a call for more robust evidence.25 These studies highlight the importance of prioritising the control of systolic BP over diastolic BP. 95% CI 1. Current NICE/RCOG guidelines therefore do not recommend treating hypertension of systolic BP of 140–149 mmHg or diastolic BP of 90–99 mmHg. occurred at lower systolic BP levels in pregnancy (mean peak systolic BP of 173 mmHg). except in those women with target-organ damage secondary to chronic hypertension. BP thresholds for treating severe hypertension For women with severe hypertension. stroke increased by 3% (adjusted OR 1. the review failed to demonstrate a significant effect on preterm births or caesarean sections in those given antihypertensives. there is consensus that antihypertensive treatment should be given to reduce the risk of maternal central nervous system complications. whereas only 13% had a diastolic BP of at least 110 mmHg.13) for every mmHg increase in diastolic BP. If BP is underestimated or overestimated through inaccurate measurement. A 2014 update of the Cochrane review assessing the effects of antihypertensive treatment of mild-to-moderate hypertension during pregnancy (including those with a diagnosis of pre-eclampsia)27 demonstrated a reduction in the number of women developing severe hypertension or requiring a second treatment agent. compared with 8% (adjusted OR 1. although this is largely based on extrapolation of risk. The NICE23 guidelines on hypertension in pregnancy define mild hypertension as diastolic BP of 90–99 mmHg and/or systolic BP 140–149 mmHg.03–1.24 A retrospective cohort study of women with eclampsia showed that posterior reversible encephalopathy syndrome.00– 1. well-powered studies demonstrating reductions in adverse clinical outcome (maternal stroke. but the specific thresholds for initiating treatment are based on limited evidence. compared with non-pregnant patients with hypertensive encephalopathy (mean peak systolic BP of 191 mmHg).26 BP thresholds for treating mild-to-moderate hypertension There is a lack of consensus among the obstetric community regarding the threshold of treatment for mild-to-moderate hypertension in pregnancy.Pregnancy BP measurement the clinical setting and that arm circumference is correctly estimated or measured. Furthermore. progressive renal and other end-organ disease. and heart failure) following antihypertensive treatment in these cases are limited. If in doubt. moderate hypertension as diastolic BP 100–109 mmHg and/or systolic BP 150–159 mmHg.

4%] versus ‘tight’ [30. ambulatory BP devices have been used to assess women at home.80–1. The use of mean arterial pressure Evidence is conflicting regarding the utility of mean arterial pressure (MAP) in pregnancy.76 (95% CI 0.27 In contrast. but who present with an elevated BP to a healthcare provider.Nathan et al. 95% CI 1.3 However. adjusted OR 1. and assess patterns of BP variation throughout the day. Therefore it is suggested that treatment to a target diastolic BP of 85 mmHg is optimal.72).64–0. It has long been recognised that automated 24-hour BP readings improve the identification of women who are at risk of poor obstetric outcome.82) than systolic BP (0. This is reflected in the current NICE ª 2015 Royal College of Obstetricians and Gynaecologists guidelines. demonstrating that a 10 mmHg fall in BP was associated with a 145g decrease in birthweight.7% versus 2. is more acceptable to women and provides many of the advantages of ambulatory monitoring. statistically significant differences in 24-hour BP are seen in women with subsequent hypertensive versus normotensive pregnancies. Whitecoat hypertension has been shown to be an independent predictor of cardiovascular risk. 95% CI 0.33 Despite this. 95% CI 0.68.42 Importance of vital sign monitoring in the diagnosis and management of obstetric haemorrhage and sepsis Obstetric haemorrhage.0%. adjusted OR 1.38 More recent evidence has shown that as early as the first trimester. In the home setting. However. This recommendation is supported by a meta-regression analysis of the relationship between feto-placental growth and use of antihypertensives.80. Further studies are required to better establish the predictive value of MAP in hypertensive disorders in pregnancy and the thresholds that should trigger intervention. adjusted OR 1.74. Ambulatory/self-monitoring White-coat hypertension describes a group of individuals who are normotensive in their home environment.97. considering the risk of adverse cerebrovascular outcomes at higher systolic BP.35) and secondary outcomes (one or more serious maternal complications) (3.02.7%]. the use of ambulatory monitoring should be encouraged and expanded in the obstetric population. ambulatory readings enable differentiation of true white-coat hypertension from hypertensive disorders in pregnancy.39 Ambulatory BP monitoring is well tolerated with high rates of compliance. the Cochrane review on mild-to-moderate hypertension in pregnancy27 demonstrated no overall effect on the relative risk (RR) of having a small-for-gestational-age baby (RR 0.23 which do not refer to MAP for diagnosing or treating hypertensive disorders in pregnancy.6%] versus ‘tight’ [27. to overcome the low sensitivity and specificity of clinic BP measurement.38).35 Diurnal variation in BP is a well-documented phenomenon. 95% CI 0. the AUROC value is modest and lack of familiarity with MAP thresholds and the difficulty in obtaining MAP from many devices makes its clinical utility limited.66. delivery and 95 . and lead to an increase in small-forgestational-age infants.79–3.34 A prospective observational study of women with chronic and white-coat hypertension in pregnancy demonstrated that 40% of those with white-coat hypertension developed hypertensive disorders in pregnancy and 8% developed pre-eclampsia. our understanding of haemodynamic changes during pregnancy.70–0. 95% CI 0.17) in those receiving antihypertensive treatment compared with placebo.84) between the two groups. 95% CI 0. There were similar rates of the primary (perinatal) outcome (a composite of pregnancy loss or high-level neonatal care for more than 48 hours in the first 28 days of life) between the two groups (‘less tight’ [31.32 However. sepsis and unsafe abortion contribute to almost half of all maternal deaths globally. A 2008 predictive accuracy systematic review and meta-analysis demonstrated that MAP measured in the first and second trimester of pregnancy may be a better predictor of pre-eclampsia (area under the receiver operator curve (AUROC) 0.36 and is seen to be reversed in those with severe hypertensive disorders in pregnancy towards the end of pregnancy. cheaper.5%]. owing to the concern that overtreated hypertension could compromise uteroplacental and fetal circulation.31 Women with non-proteinuric hypertension were randomised to either ‘tight’ (target diastolic BP 85 mmHg) or ‘less tight’ BP control (target diastolic BP 100 mmHg). respectively. significantly fewer than the 22% with chronic hypertension who developed pre-eclampsia (P<0. the majority of which occur in LMICs. while also improving surveillance and reducing scheduled visits. in pregnancies complicated by hypertension or pre-eclampsia this change in circadian rhythm may be altered.77–1.31 Recommended lower limit of diastolic BP The NICE guidelines23 recommend keeping diastolic BP above 80 mmHg during pregnancy in women receiving antihypertensive treatment.35–2.40 and with established ‘reference ranges’41 in pregnancy.59–0.37 Automated. the management of mild-to-moderate hypertension in pregnancy (Control of Hypertension in Pregnancy [CHIPS] study) is in progress and preliminary results are available. which is prone to all the biases of observational studies.72) or diastolic BP (0. The use of self-monitoring is simpler. women receiving ‘less tight’ control were more likely to develop severe hypertension (‘less tight’ [40. concern has been raised regarding the meta-regression design.008).

demonstrating adequate value for predicting maternal morbidity but suggesting that further refinements were required. there are a small number of studies suggesting that severe systolic hypertension is a better indicator than diastolic hypertension of the risk of adverse cerebrovascular events. a pregnant population. were poor predictors of blood loss.48 This is especially problematic in some LMIC settings.74 for pulse and 0. the evidence regarding the use of vital signs in the diagnosis and management of maternal shock is limited. sepsis and unsafe termination of pregnancy contribute to more than half of all maternal deaths globally. with assessment of the efficacy of varying antihypertensive drug classes. more recently. Conventional vital signs as predictors of adverse clinical outcome A healthy woman can lose up to 30% of her blood volume before a change in systolic BP becomes apparent.44 These refinements will only be possible if there is a research focus on robust pregnancy-specific validation studies of the vital sign thresholds used on MEOWS charts. misleading the healthcare provider as to haemodynamic stability and delaying vital interventions. Shock Index as a marker of haemodynamic instability Shock Index.45 A 2013 systematic review examining the relationship between blood loss and clinical signs in obstetric haemorrhage found that pulse and systolic BP. to date. particularly regarding mild-to-moderate hypertension.56–0. commonly used to assess haemodynamic status.84. For severe hypertension. The diagnosis and management of each of these conditions is guided. as an earlier marker of compromise than 96 conventional vital signs.7 indicating the need for urgent attention. likely due to the physiological compensatory mechanisms of pregnancy.46 However. This report. recommended the use of a modified early obstetric warning score (MEOWS) chart for all pregnant and postpartum women in order to trigger intervention in those at risk of haemodynamic compromise.46 Relying on conventional vital signs to prompt diagnosis and treatment of shock may contribute to avoidable morbidity and mortality. Healthcare professionals should be aware of the advantages and disadvantages of the various BP devices available and feel confident to raise concern regarding devices inaccurate for use in pregnancy or poor technique observed. but more studies in this area are required. only two retrospective studies have attempted to define the normal range of Shock Index in women with obstetric haemorrhage according to risk of adverse clinical outcome. Further well-designed clinical studies and trials are required to evaluate the optimal threshold for intervention in women with different types of hypertension in pregnancy. to Modified early obstetric warning score charts The 2006–2008 Confidential Enquiries report4 suggested that many maternal deaths could be prevented by more timely detection and intervention in haemodynamic compromise.56–0.50 The use of Shock Index in the assessment of women with shock secondary to obstetric haemorrhage or sepsis may help more promptly identify those at risk of avoidable mortality and morbidity. ª 2015 Royal College of Obstetricians and Gynaecologists . Likewise.Pregnancy BP measurement postpartum. by the measurement of BP.49. as well as the 2011 statement from the UK Maternal Critical Care Working Group.77–0.50 and one of the studies also suggested a second threshold of at least 1. where the limited resources available may not be adequate to prevent mortality and significant morbidity when haemodynamic instability is eventually recognised.9. a national standardised chart does not exist and there is concern that pregnancy-specific evidence supporting the vital sign thresholds used on these charts (particularly BP and pulse) is lacking. the ratio of pulse to systolic BP. the national guidelines for hypertensive disorders in pregnancy on intervention according to BP thresholds are largely based on expert opinion. compared with 0.4 Research should now focus on determining the optimal vital sign predictor(s) and thresholds of this predictor to guide assessment in obstetric shock. A systematic review has demonstrated that Shock Index was an accurate indicator of decompensation in both non-pregnant individuals and pregnant women (with AUROCs ranging 0. has been proposed in a nonpregnant and. in part.43 Despite this recommendation. In the absence of high-grade evidence. and the pathophysiological response compromise in these conditions remains limited. Both studies concluded that the upper limit of normal Shock Index was 0.47. It is therefore important that clinicians caring for women with these conditions are able to measure BP correctly and to appreciate the importance of accurate measurement. The impact of recognition of haemodynamic compromise on mortality and significant morbidity was highlighted in the 2006–2008 Confidential Enquiries report.44 Only in 2012 was the most commonly used MEOWS chart first evaluated. Conclusion Hypertensive disorders in pregnancy.4.79 for systolic BP). obstetric haemorrhage. and the significance of the measurement which is often very different from non-pregnant patients.

Shennan A. et al. Ayala DE. Cushman J. 22 Oliveira SMJV. Drafting the article or revising it critically for important intellectual content (HLN. and preeclampsia. Murphy KE. Taylor RS. Fall in mean arterial pressure and fetal growth restriction in pregnancy hypertension: a meta-analysis. Posterior reversible encephalopathy syndrome and eclampsia: pressing the case for more aggressive blood pressure control. Farrell T. Incidence. 97 . et al. Jensen PL. Cox JG. N Engl J Med 2015. Cochrane Database Syst Rev 2014. 34 Stergiou GS. Shennan AH. Wilkinson LS. BMJ 2008.372:407–17. et al.24:58–63. Drife J. BJOG 2005.105: 246–54. Lack of reproducibility in pregnancy of Korotkoff phase IV as measured by mercury sphygmomanometry. Paczka-Zapata JA. Lambert PC. KD. 19 Natarajan P. Baker AB. BJOG 2011. An audit of the use of sphygmomanometers. random error. Br J Obstet Gynaecol 1991. NICE clinical guideline 107. Hoey J. Terminal digit preference. Coleman AJ. Arcuri EA. 8 Shennan A. Bewley S.38:180–9. 30 North RA. Moore RC. Duley L. Beilin LJ. The British Hypertension Society protocol for the evaluation of blood pressure measuring devices. or analysis and interpretation of data (HLN. Shennan A. 21 Fonseca-Reyes S.112:601–6. Pierin AM. Schwartz GL.181:1203–10. 4 Cantwell R. de Alba-Garcıa JG. The Lancet Global Health 2014.112:915–20.36:149–58.352:777–81. Blood Press Monit 2010. von Dadelszen P. Beevers DG. de Swiet M. Prevention and treatment of postpartum hypertension. et al. Mol BW. Petrie J. Vollebregt KC.9:249–53. 29 Bramham K. Vrieze Nd. Karpettas N. 11 Perry IJ. Hypertension 2014. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008. Thijs L. De Swiet M. Seed P. Magee LA. BMJ 2013.120(2 Part 1):318–24. 26 Scott CA. Parati G. The natural history of white coat hypertension during pregnancy. Craici IM. 13 Hussain A. Asmar R.46:1187–93.2:e323–33. European Society of Hypertension International Protocol revision 2010 for the validation of blood pressure measuring devices in adults. Asztalos E. Taylor DJ. Steel SD. Am J Obstet Gynecol 1999. LCC. Shennan A.336:1117–20. Brown MJ. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Hypertension in pregnancy: which method of blood pressure measurement is most predictive of outcome? Obstet Gynecol 1996. Cooper G. Global 3 Say L. Randomised trial of management of hypertensive pregnancies by Korotkoff phase IV or phase V. Calibration accuracy of hospital-based non-invasive blood pressure measuring devices. de Swiet M. Clin Sci Mol Med Suppl 1976. Blood Press Monit 2004. Fernandez JR. Pijnenborg R. Pre-eclampsia. risk factors.10:181–8. Blood-pressure measurement and classification in pregnancy. de Swiet M. causes of maternal death: a WHO systematic analysis. et al. Niiranen TJ. KD. How frequent are arms of a ‘large circumference’? Blood Press Monit 2003. Bonnar J.376:631–44. Effects of systematic errors in blood pressure measurements on the diagnosis of hypertension.33:130–7. Lancet 1996. Tuncßalp O. Prognosis of white-coat and masked hypertension: International Database of HOme blood pressure in relation to Cardiovascular Outcome. management. 25 Wagner SJ. LCC. Anthony J. London: NICE. Conflicting views on the measurement of blood pressure in pregnancy. Obstet Gynecol 2012. ª 2015 Royal College of Obstetricians and Gynaecologists 17 O’Brien E.15:23–38. 23 National Institute for Health and Care Excellence. € Moller AB. Blood pressure patterns in normal pregnancy. Stergiou G. Jones M. AHS). 37 Redman CW. Wingo MT. Final approval of the version to be published (HLN. Thigpen BD. J Hypertens 1993. Lancet 2010. J Adv Nurs 2002. Wilton A. Comparison of auscultatory and oscillometric automated blood pressure monitors in the setting of preeclampsia. J Clin Epidemiol 1993. Garrod D. Schellenberg JC. NLH.347:139–42. gestational hypertension. 27 Abalos E. Kollias A. Mangos G.Nathan et al. Taylor DJ. Br J Obstet Gynaecol 1999. Kurinczuk JJ. 14 Coleman AJ. Alonso I. Ross S.63:675–82.11(Suppl 2):S43–62. et al. All authors had full access to all of the data in the study and can take full responsibility for the integrity of the data and the accuracy of data analysis. How accurate are sphygmomanometers? J Hum Hypertens 1998. Disclosure of interests No conflict of interest is declared. Rey E. An accurate automated blood pressure device for use in pregnancy and pre-eclampsia: the Microlife 3BTOA. et al. Davis G. Steyn DW. et al. References 1 Duley L. Postpartum management of hypertension. 35 Brown MA. London: NICE. Lancet 1998. May W. Br J Clin Pract 1996.346:30–4. Vowler SL.118 (Suppl 1):1–203. De Swiet M. 6 Higgins JR. AHS). J Hum Hypertens 2010. Less-tight versus tight control of hypertension in pregnancy. Hypertension 2000. von Dadelszen P. 2 Steegers EA. 28 Magee L. Asayama K. Rose CH. Koren G. 38 Peek M. Logan AG. LCC. 20 Reinders A. Rudd A. Bull SB. Chappell LC. Nelson-Piercy C. Lancet 2001.355:87–92. Duvekot JJ. Blood Press Monit 2005. Cuff width influence on blood pressure measurement during the pregnant-puerperal cycle. Hozawa A. Lancet 2000. et al. Rose CH. Effect of standard cuff on blood pressure readings in patients with obese arms. Accuracy of mean arterial pressure and blood pressure measurements in predicting pre-eclampsia: systematic review and meta-analysis. 10 Mion D. Parra-Carrillo JZ. Dawson A. Semin Perinatol 2009.(1):CD004351. 32 von Dadelszen P. or acquisition of data. Contribution to authorship Substantial contributions to conception and design. Buddle ML. Daniels J. Chou D. 7 Brown MA. Hanley JA. No financial relationships with any organisation that might have interest in the submitted work in the previous three years are declared.3:687s–689s. Halligan A.88:1030–3. 36 Hermida RC. 18 O’Brien E. 9 de Greeff A. Halligan A. Lindell EP. Obstet Gynecol 2005.161:729. et al. Halligan A. 15 Turner MJ. Kramer MS. NICE Clinical Guideline 62. Davis G. Silva I. Lorde I. Mojon A. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. KD. and outcomes of stroke in pregnancy. Franx A. AHS).106:767–73. BJOG 2005. Gupta M. No other relationships or activities that could appear to have influenced the submitted work are declared. Shinton RA. 16 Canzanello VJ. Homer C. Altman D.12:245–8. 31 Magee LA. Kam PC. Cochrane Database Syst Rev 2005. Cuckson AC.(2):CD002252. 5 National Institute for Health and Care Excellence. Are aneroid sphygmomanometers accurate in hospital and clinic settings? Arch Intern Med 2001. Ornstein MP. Sadeghi S. King’s College London is the guarantor for the study. 2008. Acquah LA. Spark P. The global impact of pre-eclampsia and eclampsia.357:131–5. NLH. Ashworth M. Littler W. Padfield PL. Hypertension in Pregnancy: The Management of Hypertensive Disorders During Pregnancy. 24 Martin JN Jr. Mayo Clin Proc 2011. Antenatal Care. and bias in routine clinical measurement of blood pressure. 33 Cnossen JS. Lee JT.86:851–6. Shennan AH. 2010. Santos JLF. Usher RH. Evaluation of a definition of pre-eclampsia. Penny J. Brocklehurst P. Clutton-Brock T.8:101–6. Gemmill A. Accuracy of the pressure scale of sphygmomanometers in clinical use within primary care. Reversed diurnal blood pressure rhythm in hypertensive pregnancies.98:241–3.50:136–7. Atkins N. 12 Wen SW. Gt Riet. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy.

44 Singh S.20:135–56. Winikoff B. Simons R. PLoS One 2013.11:869–73. O’Brien E. London: Royal College of Anaesthetists. Williams & Wilkins. 42 Ross-McGill H. Hewison J. Atkins N. Hermida RC. 49 Le Bas A. Sterner S. Twentyfour-hour ambulatory blood pressure measurement in a primigravid population.122:268–75. Massive Post Partum Hemorrhage. Iglesias M. Am J Emerg Med 2001. Gaeta TJ. et al. Heegaard WG.30: 233–59. A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS). McGlennan A. Chandraharan E. Mee F. ª 2015 Royal College of Obstetricians and Gynaecologists .107:217–21.189:1293–6. Shock index: an effective predictor of outcome in postpartum haemorrhage? BJOG 2015. 43 The Maternal Critical Care Working Group. Anaesthesia 2012. 2011. Dowswell T. Van Deusen SK. Rodgerson JD. 46 Pacagnella RC. Brunskill P. 50 Nathan H. 98 45 Troiano N. Int J Gynaecol Obstet 2013. Chronobiol Int 2003. Ayala DE.19:488–91. Souza JP. Conroy R. Chez B. Circadian rhythm of blood pressure challenges office values as the “gold standard” in the diagnosis of gestational hypertension. Philadelphia: Lippincott. 41 Halligan A.67:12–8. Chronobiol Int 2013. Blum J. Seed P. 40 Hermida RC. Perel P. Holt A. Arulkumaran S. Use of the “obstetric shock index” as an adjunct in identifying significant blood loss in patients with massive postpartum hemorrhage. In: AWHONN’s High Risk and Critical Care Obstetrics. 2012. Durocher J. Harvey C. 47 Birkhahn RH. BJOG 2000. El Ayadi A. Vital signs fail to correlate with hemoperitoneum from ruptured ectopic pregnancy. Antenatal home blood pressure monitoring: a pilot randomised controlled trial. Am J Obstet Gynecol 2003. 48 Hick JL. Tloczkowski J. England A. Miller S. J Hypertens 1993. Hezelgrave N.Pregnancy BP measurement 39 Ayala DE. Addei A. Butrick E. Ambulatory blood pressure monitoring for the early identification of hypertension in pregnancy. Hirst J. et al.8:e57594. The ability of traditional vital signs and shock index to identify ruptured ectopic pregnancy. et al. A systematic review of the relationship between blood loss and clinical signs. Providing Equity of Critical and Maternity Care for the Critically and Maternity Care for the Critically Ill Pregnant or Recently Pregnant Woman.124:253–5. et al. O’Malley K.