A prospective randomized study of automated versus mercury blood pressure recordings in hypertensive pregnancy (PRAM Study).

BACKGROUND: Mercury sphygmomanometry is being replaced with automated blood pressure (BP) recording. We tested the potential impact of this change on the outcomes of pregnant women with hypertension. METHODS: Following routine detection of hypertension by mercury sphygmomanometry, 220 pregnant women with hypertension were randomized to have all subsequent BPs recorded with either mercury sphygmomanometry or an automated BP device (Omron HEM-705CP) for the remainder of their pregnancy. We used a prospective randomized open study with blinded end points design. MAIN OUTCOME MEASURES: The primary maternal outcome measure was the number of women having any episode of severe hypertension (BP 170/110 mmHg). The primary fetal outcome measure was small for gestational age baby. RESULTS: Both groups were similar in age, weight, parity, race, use of assisted reproductive technology before this pregnancy, diabetes prevalence, smoking, mercury BP in the first trimester, use of antihypertensives at the time of study entry, and type of hypertension (essential, gestational or preeclampsia) at study entry. Severe hypertension occurred in 39% of women using mercury sphygmomanometry and 44% using the automated device (p = 0.5). Small for gestational age rates were 12 and 17%, respectively (p = 0.3). About 47% of women had preeclampsia at delivery. Birth weight and perinatal mortality were similar between groups. CONCLUSIONS: Using this automated BP recording device in hypertensive pregnant women is associated with similar maternal and fetal outcomes as in women whose BP is measured by sphygmomanometry, despite intra-individual BP differences between the two methods of recording BP.

Inaccuracies in estimated glomerular filtration rate in one Australian renal centre.

BACKGROUND: Early identification of true renal disease (glomerular filtration rate (GFR) < 60 mL/min) results in better patient outcomes. There is now routine reporting in Australia of estimated GFR (eGFR) in all patients over age 18 who have serum creatinine measured, calculated by the Modification of Diet in Renal Disease (MDRD) formula, which was validated in an American Caucasian cohort. Significant clinical decisions and prognosis are often made on the basis of this calculation. AIM: To assess the accuracy of three estimates of GFR in an Australian population by comparing eGFR obtained by the abbreviated MDRD (aMDRD), Cockcroft-Gault corrected for body surface area (BSA) (CG) and Chronic Kidney Disease Epidemiology (CKD-Epi) formulae with a gold standard, isotopic (51) Cr-ethylenediaminetetra-acetic acid ((51) Cr-EDTA) GFR. METHODS: Patients referred with an eGFR of <60 mL/min reported by the aMDRD formula underwent isotopic measurement of GFR (over 4 h) and had eGFR calculated using CG corrected for BSA, aMDRD and CKD-Epi formulae. Data were analysed using Bland-Altman plots and regression analysis to compare methods; bias, precision and the proportion of patients correctly stratified by stage of chronic kidney disease (CKD) were also compared according to the three estimates of GFR, using (51) Cr-EDTA GFR as the gold standard. RESULTS: A total of 139 patients were recruited (female 45%), mean age 64 years and mean serum creatinine 212 µmol/L. The mean GFR (SD) (mL/min per m(2) ) for isotopic, CG, aMDRD and CKD-Epi were 47 (28), 37 (20), 32 (17) and 33 (18) (P = 0.001). CG (57%) was more likely to correctly stage CKD than aMDRD (37%) or CKD-Epi (37%), and absolute bias was significantly lower using CG than either other method (P = 0.001). CONCLUSION: In this small Australian population the CG formula corrected for BSA agreed more closely with isotopic GFR and correctly staged patients with CKD more often than the aMDRD or CKD-Epi formulae. It is important that each renal Unit considers the accuracy of estimates of GFR according to their population demographics.

Predicting transformation from gestational hypertension to preeclampsia in clinical practice: a possible role for 24 hour ambulatory blood pressure monitoring.

OBJECTIVE: To identify parameters that may assist clinicians in predicting which women will develop preeclampsia (PE) after initially presenting with gestational hypertension (GH). METHODS: 118 women were recruited to the study with GH or PE. They were divided into three groups based on their diagnosis at delivery- (1) GH, (2) PE from the time of presentation, (3) those with an initial diagnosis of GH who progressed to PE. Women underwent 24 hour ambulatory blood pressure monitoring (ABPM) and had serum estrogen, progesterone, beta-HCG, leptin and adiponectin measured as possible predictors of transformation of GH to PE. RESULTS: Women who presented with GH, and progressed to PE, presented four weeks earlier (33 vs 37 weeks, p < 0.001) than those who did not progress. Women with PE, either as their initial diagnosis or after progression from GH, were delivered earlier (p < 0.001) and had more small for gestational age (SGA) babies than women with GH at delivery (p < 0.05). Those who developed PE after presenting with GH generally had higher blood pressures than those who remained as GH, significant for awake and 24 hour systolic blood pressures (p < 0.05). beta-HCG, estrogen, progesterone or leptin values were similar across the groups. Adiponectin was higher in women with established PE at presentation compared to women with GH (p = 0.02) but adiponectin failed to discriminate those women with an initial diagnosis of GH who progressed to PE. CONCLUSION: 24 hr ABPM may provide a non-invasive method of identifying this 'at risk' GH population, particularly in the case of early presentation.