[CG] Home blood pressure and urinalysis monitoring – Clinical Guideline

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Introduction

Raised blood pressure (BP) affects approximately 10% of pregnancies worldwide; almost half of these women develop pre-eclampsia. Globally, around 15% of maternal mortality is due to preeclampsia so early detection and prevention are paramount. 

The COVID-19 pandemic has required the NHS to urgently consider self-monitoring of BP at home by pregnant women in order to safely reduce the number of face-to-face consultations for pregnant and postnatal women. 

Self-monitoring of BP at home by pregnant women can either be used to replace measurement of blood pressure by a healthcare professional on the day of a scheduled clinic (i.e. intermittently) or can be done routinely and more frequently by pregnant women (e.g. daily or weekly) in addition to usual care.

Which women are eligible for Home BP monitoring?

Self-monitoring of blood pressure by pregnant women is going to be rolled out in phases to high-risk women.   Home monitoring will be initially targeted to women at high-risk of hypertensive complications or who are ‘shielded’ because of serious underlying medical conditions (Group 1), followed by women identified at increased risk of hypertensive complications (Group 2). 

Home blood pressure monitoring should NOT replace any appointment where a woman is receiving clinical review for her underlying medical condition (e.g. for respiratory review of cystic fibrosis or cardiac review of underlying cardiac condition) or where fetal assessment is required as part of the clinical review. 

All requests for home BP monitoring in GGC must be discussed and approved by a consultant.  The named consultant must have recorded in BadgerNet that they agree to home monitoring and outline the follow-up plan.

Group 1
Women identified as 'high risk' of hypertensive complication including: 

  • Chronic Hypertension
  • Current Gestational Hypertension (Pregnancy Induced Hypertension, PIH)
  • Current Pre-eclampsia

Women who have been advised to shield because of serious underlying medical conditions:

  • Cystic Fibrosis
  • Solid organ transplant
  • Cardiac conditions

 

Group 2
'Increased risk' of developing Pre-eclampsia

  • Hypertensive disease during a previous pregnancy
  • Chronic Kidney Disease
  • Autoimmune disease (eg SLE / Antiphospholipid syndrome)

 

All women being considered for home blood pressure monitoring must fulfil the following clinical inclusion and exclusion criteria: 

Inclusion criteria  

  • Systolic BP range ≤140 mmHg
  • Diastolic BP range ≤100 mmHg
  • Proteinuria ≤ 1+ on urine dipstick
  • Normal full blood count, liver and renal function blood tests as baseline and when new proteinuria present

Exclusion criteria  

  • Maternal age <16 years at booking.
  • Systolic BP >140 mmHg
  • Diastolic BP >100 mmHg
  • Proteinuria ≥ 2+ on urine dipstick
  • Symptoms of headaches, visual symptoms, epigastric pain
  • Significant mental health concerns
  • Women who are not capable of giving informed consent
  • Women who are not able to operate home blood pressure equipment
  • Fetal growth restriction
  • Women not wishing to take this responsibility

Eligibility should be considered on an individual basis for each woman, and in context of other pregnancy care guidance.   Consideration should be given to ensuring that the woman has sufficient digital literacy, data/internet and devices to participate in remote consultations.

Clinical Pathway

  1. Arrange for a woman to attend face to face appointment in Daycare Unit. Ask her to bring her mobile phone with her to the appointment. If a woman already has a blood pressure monitor at home, all NHS-issued monitors are validated. If she owns her own device, ask her to bring it to the appointment so the obstetrician can check it is suitable for use in pregnancy. 

  2. Provide antenatal or postnatal check as usual. Assess eligibility to participate in self-monitoring of blood pressure and urinalysis. Ensure contact details are up to date on BadgerNet (home, mobile phone, number, and email).

  3. Provide an NHS device and an appropriately sized cuff (check upper arm measurement). In some cases, proxy measures may be taken from the forearm. Complete a blood pressure monitor loan form with the woman, ensuring the asset is appropriately labelled and tracked and informed consent is given.

  4. If a woman has brought her own blood pressure monitor to the appointment, validate it as suitable for pregnancy and puerperium. The following are validated monitors:

  1. Give written instructions on how to take a blood pressure reading (patient information leaflet) and signpost the link to the short video: British Heart Foundation - How to take your own blood pressure. Use teach-back to show the woman how to take her own blood pressure, write down and interpret her results. Ask the woman to take her blood pressure by herself twice, at least one minute apart, to demonstrate understanding (patient information leaflet).

  2. Give written instructions on how to self-monitor for proteinuria and glycosuria (patient information leaflet). As above, use teach-back to ensure the woman understands how to use the test and where and how to record her results.

Glycosuria detected by routine antenatal testing: be aware that glycosuria of 2+ or above on 1 occasion or of 1+ or above on 2 or more occasions detected by reagent strip testing during routine antenatal care may indicate undiagnosed gestational diabetes. If this is observed, consider further testing to exclude gestational diabetes.  

  1. Give written instructions on expected frequency of blood pressure monitoring and urinalysis, making clear whether this will be done in place of usual care (e.g. on the morning of a scheduled telephone/ virtual clinic appointment) or in addition to usual care (e.g. once a week, three times a week etc).

  2. Make clear home-readings will not be reviewed by a healthcare professional unless it is before a pre-organised clinic appointment or virtual contact. Women should be discouraged from recording readings at unspecified times.  However, ensure she understands who to contact if she is concerned.  
     
  3. If a woman requires additional investigations / appointments (e.g. growth scan, obstetric clinic follow-up etc), arrange as per local guidelines.

  4. Provide a paper blood pressure recording diary and show her how to use it.

  5. Please inform the woman that it is vital that they follow the written instructions and phone the hospital contact number if they develop raised blood pressure, new proteinuria, increasing proteinuria, or new symptoms.

  6. Book the next appointment with the woman and discuss whether this will be telephone (or other remote working) or face-to-face. A robust plan must be documented in BadgerNet for named consultant review in some format.

  7. Inform the GP that the woman is undertaking home blood pressure monitoring.

  8. Explain the arrangements to the woman for the return of the blood pressure monitor (local arrangements). Once returned, wipe the blood pressure monitor thoroughly with a cleaning wipe, and check that all components are correct.

How to interpret home monitoring

An overview of home blood pressure monitoring