Title: Identification and treatment of women with hypertensive disorders of pregnancy: translating evidence into practice
Funder: Department of Health and Social Care

Abstract: Hypertensive disorders (HDP) affect up to 20% of pregnancies and their prevalence is increasing. Pre-eclampsia (hypertension with proteinuria) the more severe end of the HDP spectrum is a leading cause of maternal and infant mortality and morbidity and both gestational hypertension and pre-eclampsia are related to future maternal cardiovascular disease and greater offspring BMI in later life. Failure to recognise and treat HDP effectively contributes to the increased risk of morbidity and mortality. Current NICE antenatal care guidelines1 recommend assessment of blood pressure (BP) and proteinuria at each antenatal visit, (10 visits are recommended for nulliparous and seven visits for multiparous women) this strategy is used to identify when a woman has developed a HDP rather than the earlier identification of those women at risk of HDP and in whom prevention of these conditions might be possible. Use of BP trajectories (pattern of BP changes across pregnancy) may provide a way of predicting risk of HDP and allow targeting of surveillance and an opportunity to provide interventions designed to reduce the risk of disease development and adverse perinatal and long term ill-health outcomes. I will undertake an epidemiological analysis using data from the Born in Bradford Cohort (13,000 White British and South Asian pregnancies) and examine associations between BP trajectories and risk of HDP and adverse perinatal outcomes. Use of evidence based guidelines can increase the quality of care, effectiveness of treatment and reduce unwarranted variation in practice. The National Institute for Health and Care Excellence (NICE) in the UK2 and similar institutions in other countries have produced high quality guidelines for the identification and management of HDP. However even with these guidelines in place there is evidence of continuing failures in care; consequently the risk of morbidity remains higher than it should be. I will explore practice before and after the publication of the NICE hypertension in pregnancy (HiP) guideline2 and the extent of adherence to these recommendations, between and within UK centres. I will also investigate the reasons for variation and how adherence to the NICE guideline might be improved. To obtain a full understanding of the degree of NICE HiP guideline adherence, I will conduct a cross-sectional analysis of maternal records from a randomly selected sample of maternity units across the UK.3 I will interview, using a grounded theory approach4; 5 up to six obstetricians and six midwives (from hospitals previously selected for the maternal records review, to explore their perceptions of the barriers and enablers to use of the NICE guideline recommendations. Finally I will conduct a judgement analysis6 of midwives and obstetricians (including those previously interviewed) to examine the accuracy, consistency and ways that important information is used in clinical reasoning, for a selection of judgements and decisions commonly undertaken. Dependent on the findings, the epidemiological analysis planned may provide evidence for a new effective strategy for the prediction of HDP, I want to make sure that these findings (as well as existing evidence) are rapidly translated into clinical care and this can only be done if there is an effective implementation strategy.7 There is however evidence that a lag or gap' remains between the generation of evidence and its successful translation into clinical care. The work planned on the clinical HiP guideline adherence and judgement and decision making will inform the development of an intervention targeted at improving the translation of evidence based care through the reliable use of the NICE HiP guideline. The successful translation of evidence based care into clinical practice will help improve outcomes for women and their infants.

Lay abstract: One in five women experience high blood pressure (BP) during pregnancy; which can harm them and their babies. Using information from a large pregnancy cohort study I will explore how to better identify early in pregnancy, those women who will go on to develop high BP and to have poor health outcomes. I will also assess the extent, and reasons why clinical practice varies across England for the identification and care of women with high BP. This research will help to improve care and health outcomes for pregnant women and their babies.

Research activity codes: 4.1 DISCOVERY AND PRECLINICAL TESTING OF MARKERS AND TECHNOLOGIES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH