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Guidelines in rural practice
Management of hypertension in pregnancy in rural areas
  1. M Maresh
  1. Consultant Obstetrician, St Mary’s Hospital for Women and Children, Manchester M13 0JH, UK; michael.maresh{at}cmmc.nhs.uk

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    If we are to develop national guidelines, they must encompass all regions of the country and make allowances for rural areas.

    Hypertension in pregnancy remains one of the leading causes of maternal deaths with approximately 1 in 100 000 women in the UK dying from complications associated with it.1 In other parts of the world the figure is higher. Maternal and perinatal morbidity is relatively common in the 0.5–1% of women who have severe hypertension, with eclamptic fits occurring in about 1 in 2000 pregnancies.2 However, hypertension in pregnancy is also a common complication with up to 10% of pregnant women having a significant rise in blood pressure in the third trimester. Furthermore, complications may develop rapidly with a minimal rise in blood pressure. Encouraging pregnant women to have as much antenatal care as possible in the community therefore produces challenges for health professionals. They have to be able to predict the small number who may develop severe complications so that they can be appropriately managed to minimise the risk of maternal and perinatal morbidity and mortality.

    Such challenges are even more marked in rural areas with poor routes of communication. Studies in other medical specialties have shown a tendency for more patients to be referred to central hospitals from rural areas because of anxieties that complications may occur in non-ideal settings. Local guidelines have often been produced to assist in the process. In Scotland a guideline for the management of non-proteinuric hypertension in pregnancy has been compiled using the methodology of the Scottish Intercollegiate Guidelines Network (SIGN).3 Guidelines produced in this way are highly regarded, having been subjected to a rigorous development process. They are widely circulated and are sent to all general practitioners providing maternity care in Scotland. However, despite the fact that hypertension in pregnancy is a common condition, there is little evidence based on randomised controlled studies so most of the recommendations are graded as level B or C.

    In this issue of QSHC Tucker et al4 report a study in which they investigated the management of hypertensive conditions in pregnancy to see whether this guideline was used in practice. A questionnaire approach was used involving two clinical scenarios. Only minimal information was given—including maternal age, gestation, blood pressure recording, and the degree of proteinuria. The study found that most of the general practitioners and midwives working in rural settings did not follow the guideline and tended to over-refer or arrange emergency hospital admissions.

    WHY ARE THE GUIDELINES NOT BEING FOLLOWED?

    One of the problems in translating guidelines into practice is that clinicians may not want to follow them precisely when the evidence base is not very robust. An example from the study by Tucker et al is the recommendation in the guideline of a diastolic BP cut off of 90 mm Hg; some clinicians feel that an incremental rise in diastolic BP of more than 25 mm Hg during pregnancy is significant, and this may occur in young women with a diastolic BP of less than 90 mm Hg. Another example is the controversy in obstetrics as to whether to use the Korotkoff phase IV (muffling) or V (disappearance) of the pulse as a measure of the diastolic blood pressure. A further problem arises when a key measurement on which management is based is somewhat subjective. In the study by Tucker et al one of the two scenarios described a woman with “+” proteinuria according to the dipstick test. If she had had “++” proteinuria the management would have been different. Bearing in mind the subjectivity of interpreting the colour differences between “+” and “++” on urine dipstick tests for proteinuria, one can perhaps begin to understand why the health professionals tended to err on the side of caution in their management of the patient.

    A further point concerning the use of guidelines is whether an appropriate measure of compliance is used. In this study one could take issue with the authors for devoting a whole table to semantics. They criticise health professionals for using the term “pre-eclampsia” to describe the scenario of mild hypertension and “+” proteinuria because the guideline refers to it as “mild hypertension”. This is despite the fact that the guideline admits that multiple names are used for the condition.

    It is also important to consider whether the guideline is actually appropriate for a particular population. Tucker et al looked at the uptake of guidelines in rural settings and, in particular, analysed the results by the distance of the practice from a specialist hospital. In keeping with other studies, they found that referral or admission rather than community monitoring were more likely to be advised in cases further from hospital. However, those working in isolated rural communities are being asked to take additional responsibility for a wide range of conditions, not just hypertension in pregnancy. The authors quote one general practitioner who commented on the barrage of guidelines, the infrequency of certain conditions, the individual approach to patients, and the difficulties of management in remote communities. Perhaps he/she should have been writing this commentary as it summarises so many of the problems. Patient expectation is increasing and there has to be equity of health care. Is it correct that we should have the same admission rate for a particular hypertensive problem in a woman who lives on an island with no hospital facility and one who lives almost next to a large maternity unit? How many admissions, unnecessary in retrospect, equate to one emergency helicopter flight? Who should make these decisions? If we are to develop national guidelines, they must encompass all regions of the country and make allowances for rural areas. Although the SIGN guideline development methodology encompasses user representatives, perhaps more consideration needs to be given to ensuring additional consultation from practitioners and patients from rural communities. The sense of local ownership is one of the main determinants as to whether or not a guideline is followed.

    However, the real clinical issue is improving the support for our isolated health professionals. The authors hit the nail on the head at the end of their paper when they talk about developing “stronger partnerships between specialist centres and primary care professionals”. Piles of guidelines—even if they are readily available on the web—are not a complete substitute for individualised discussions with an experienced obstetrician. With increasing centralisation of maternity care and expansion of the number of consultant obstetricians, all referral units should have an experienced obstetrician readily available to advise, with no need to rely on relatively inexperienced trainees. Methods of communication may obviously include the telephone and facsimile. However, medicine should be moving forward with communication technologies and ensuring that newer methods are readily available for isolated communities. Diagnostic images are transferable electronically and video consultation links should be available. There is a cost but, if we are to have equity of care, there is a price to pay. Providing quality continuing education for isolated practitioners does mean they need to spend more time on education and less on direct patient care; again there is a cost, but improving standards needs investment. Education is particularly important for those practitioners who have never (or not recently) been used to a particular style of management, such as that being proposed in this guideline. Being sent a guideline is not necessarily enough to instil the confidence needed to take on the additional responsibility.

    If we are to develop national guidelines, they must encompass all regions of the country and make allowances for rural areas.

    REFERENCES

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