Stress, Mean Arterial Pressure, and Roll over Tests as a Predictor of

Pregnancy Hypertension

Nikmah Jalilah Ritonga, Diah Evawanna Anuhgera, Damayanti, Wilda Wahyuni Siregar,

Riris Sitorus and Sri Wulan

Health Institute of Medistra, North Sumatra

Keywords: Stress, Mean Arterial Pressure, Roll over Test, Pregnancy Hypertension

Abstract: All three of causes from the high maternal mortality rate (MMR) in Indonesia are bleeding, hypertension and

infection. These three main causes have changed in proportion, where bleeding and infection tend to decrease

while hypertension increases. Seeing a lot of research on stress, MAP and ROT associated with pregnancy

hypertension, but there is no method to predict pregnancy hypertension, so done research on stress, MAP,

ROTS as predictors of pregnancy hypertension. This research used a cross sectional study method. The

research subjects consisted of 50 normal tension pregnant women and 50 hypertensions, according to

inclusion and exclusion criteria. Data on characteristics, obstetric history and stress were measured using a

standard questionnaire. MAP and ROT were measured 3 times (gestational age 27, 28 and 32 weeks. The

results of the research concluded that stress, MAP and ROT are associated with the incidence of hypertension

in pregnancy. Stress, MAP and ROT can be used as predictors of pregnancy hypertension (age of pregnancy

27 and 32 weeks).

1 INTRODUCTION

The main complications causing nearly 75% of

maternal deaths are heavy bleeding, puerperal

infections and high blood pressure during pregnancy.

Globally, almost 99% of maternal deaths occur in

developing countries. The ratio of maternal deaths in

developing countries in 2015 was 239 per 100,000

live births versus 12 per 100,000 live births in

developed countries, this is still far from the target of

2030 which is 70 per 100,000 live births (WHO,

2015)

Until now the maternal mortality rate (MMR) in

Indonesia is still relatively high, which was recorded

in 2012 of 359 per 100,000 live births. This figure is

still far from the SDG’s target in 2030 of 70 per

100,000 live births.

The 3 main causes of high MMR

in Indonesia are bleeding, hypertension and infection.

Indonesia Health Profile data in 2015 shows

hypertension is the second largest contributor to

MMR and has increased from year to year, namely in

2012 (26.9%) and in 2013 (27.1%). These three main

causes have changed in proportion, where bleeding

and infection tend to decrease while hypertension

increases (Kemenkes, 2016)

Hypertension is the most frequent medical

complication in pregnancy (5-10% of pregnancy).

About 30% of hypertension is caused by chronic

hypertension and 70% is caused by pre-eclampsia -

gertational hypertension. Understanding the disease

process and its impact on pregnancy are the most

important thing, because hypertension is still a major

cause of maternal and perinatal morbidity and

mortality worldwide. Complication that occur in the

mother can include placental abruption, Disseminated

Intravascular Coagulopathy (DIC), eclampsia, kidney

failure, bleeding or liver failure, intracerebral

hemorrhage, hypersensitive enceopathy, pulmonary

edema and death. Meanwhile, complications that

occur in the fetus and neonatal include retardation of

severe intra-uterine growth retardation,

oligohdroamnion, preterm labor, hypoxia-acidosis,

neurological disorders and death (sabaruddin dkk,

2015)

In pregnancy, there is an invasion of trophoblasts

into the muscle layer of the spiral arteries which

causes degeneration of the muscle layers so that

distention and vasodilation of the spiral arteries will

result in decreased blood pressure, decreased vascular

resistance and increased blood flow to the utero

placenta. As a result, blood flow to the fetus is quite

120

Ritonga, N., Anuhgera, D., Damayanti, ., Siregar, W., Sitorus, R. and Wulan, S.

Stress, Mean Arterial Pressure, and Roll over Tests as a Predictor of Pregnancy Hypertension.

DOI: 10.5220/0009467101200127

In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 120-127

ISBN: 978-989-758-460-2

a lot and tissue perfusion also increases so as to ensure

proper growth of the fetus. This process is called

spiraling artery remodeling (Perry, H. et al, /2018)

In PE / E remodeling failure occurs which will

cause the spiral arteries to become stiff and hard so

that they do not experience distension and

vasodilation so that blood flow to the utero placenta

decreases and there is ischemia and placental

hypoxia. The impact of placental ischemia will cause

changes that can cause hypertension in pregnancy.

The mean diameter of the spiral arteries in normal

pregnancy is 500 microns while in preeclampsia 200

microns (Peres, G., et al, 2018)

High stress, anxiety or depression directly or

indirectly affect pregnancy and can cause

hypertension in pregnancy. Stress changes the

hypothalamus - pituitary-adrenal (HPA) caused an

increase in cortisol and associated cellular immune

changes (Vianna, P. et al, 2011)

Taslim’s research, et al (2016) explained that

stressed pregnant women will experience Grade 2

hypertension by 28.6% and there are no pregnant

women with stress respondent conditions in the

incidence of Grade 2 hypertension and no pregnant

women who experience stress have Grade 1

hypertension. Nasr et al (2016) also support the

previous findings, that there is a significant

correlation between depression and stress levels and

the level of education of women with hypertension in

pregnancy. These findings are in line with the theory

of anxiety / stress where stress can increase cortisol,

epinephrine & other steroids, so blood to the kidneys

decreases so renin production increases. Renin will

stimulate the formation of angiotensin I then turn into

angiotension II, then in turn stimulates aldosterone

secretion by the adrenal cortex. So that sodium and

water retention occurs in the kidney tubules, the intra-

vascular volume will increase, hypertension occurs.

Vianna et al (2011) in their medical hypothesis also

say the same thing that ongoing anxiety changes the

hypothalamus through the pituitary to govern adrenal

(HPA) secreting the hormone cortisol, the release of

this hormone causes a decrease in the sensitivity of

glucocorticoit dexamethasone (DEX) anxiety so that

cellular immunitybecomes changed so preeclampsia

occurs and can even have an effect until postpartum

(Vianna, P. et al, 2011)

Mean aerteril pressure (MAP) is the average

value of arterial pressure which is assessed by

measuring the pressure of diastole and systole and

then calculated using the MAP formula. MAP is said

to be positive if the result is> 90 mmHg and negative

if the result is <90 mmHg (Suprihatin, E. and

Norontoko, D. A, 2015)

Kenny et al (2014) in their research found a

method to predict the incidence of hypertension in

pregnant women using measurement of mean arterial

pressure (MAP), and the results showed that in

pregnant women with preeclampsia the MAP value

was higher compared to pregnant women with normal

tension (Kenny, L. C. et al, 2014)

Likewise with

Akoleker (2012) in his research explained that there

is a linear correlation between Mean Arterial Pressure

(MAP) with preeclampsia.

Taslim et al (2016) also

got the same research results where MAP was

significantly associated with hypertension in

pregnancy and abnormal MAP is 11.69 times the risk

of hypertension in pregnancy.

In general, pregnant mother will experience

physiological hematological change. Where there is a

profound effect between the mother's position on the

hemodynamic profile in the mother and fetus. In the

supine position the pressure from the inferior vena

cava (VCI) causes a decrease in venous return to the

heart and results in decreased stroke volume and

cardiac output. Turning from lateral to supine

position can result in a decrease in cardiac output by

25%, causing disruption of uteroplacental blood flow

(Sherwood, 2014). Disruption of uteroplacental flow

causes changes in the value of the hemodynamic

profile between mother and fetus as blood pressure

rises (Sherwood, L, 2014)

Roll Over Test (ROT in Figure 1 is a measurement

of blood pressure in two different positions, namely

in the left side sleeping position and the supine

sleeping position. ROT is said to be positive if there

is a change / increase in diastolic blood pressure

between the side and supine sleeping position ≥ 15

mmHg and negative when changes in diastole <15

mmHg (Suprihatin, E. and Norontoko, D. A, 2015)

Ghojazedeh et al (2013) in their research found a

new method using roll over test (ROT)

measurements, and the results showed that

significantly positive ROT values were higher in the

preeclampsia pregnant women group.

In accordance

with Walia’s findings et al (2015) where ROT values

of more than 15 mmHg in normal pregnant women

are 2.191 times more likely to develop preeclampsia

(Kaytri, S, 2016)

The high mortality and morbidity of mothers and

babies due to complications caused by hypertension

in pregnancy, was an indication of the importance of

finding a method that can be accurately to predict of

hypertension in pregnancy so that complications can

be prevented as early as possible. Until now, no

predictor has been found that matches the required

standard. Seeing the many studies on stress, MAP and

ROT associated with hypertension in pregnancy, but

Stress, Mean Arterial Pressure, and Roll over Tests as a Predictor of Pregnancy Hypertension

121

there have never been researchers who tried to

combine these three variables as predictors of

hypertension in pregnancy so it is important to

examine whether the combination of stress, MAP,

and ROT is able to be a predictor of hypertension in

pregnancy (Walia, M., D, A. S. and Gupta, G, 2015)

2 METHODS

This research was conducted at the Grandmed Lubuk

Pakam General Hospital. The Respondents in this

research were divided into 2 groups, namely the group

of normal tension pregnant women by 50 people and

hypertensive pregnant women by 50 people. The

sampling technique used accidental sampling where

patients who happened to come to do a pregnancy

examination at the time of the study at the study site

will be included in the study sample adjusted to the

inclusion and exclusion criteria.

This research is a hybrid type with a cross

sectional design and prospective cohort. Stress, MAP

and ROT assessments of normal pregnant mother with

tension and hypertension were measured at the same

time. MAP and ROT were measured 3 times, namely

27, 28 and 32 weeks gestational age in normal tension

and hypertensive mothers in pregnancy.

Instrument A is an instrument used to measure

anxiety of pregnant women using a standardized

questionnaire that is the Kessler Psychological Sitress

Scale (K10) by Kessler R. Professor of Health Care

Policy from Harvard Medical School Boston USA

which consists of 10 questions about anxiety and

depression symptoms experienced by a person in the

last 4 weeks of pregnancy to see a measure of stress.

Stress intensity is measured using ratio data.

Instrument B is a tension gauge which is a

spignomanometer to measure MAP and ROT. MAP

and ROT intensity was measured using millimeter

mercury (mmHg) ratio data.

MAP measurement work procedures is make sure

the pregnant mother is relaxed, backs leaned, feet

should be comfortable and step on the floor, Make

sure the sphygmomanometer number is visible, and

the examiner's position must also be comfortable,

Attach a cuff to the left arm of a pregnant mother with

a pipe parallel to the brachial artery. Ensure that the

pulse is in the brachial artery and start pumping until

the pulse is not palpable and mark the pressure

obtained. Put down the stethoscope bell above the

brachial artery. Turn the valve clockwise, until the

valve on the rubber pump is tightly closed. The cuff is

pumped to a pressure of 30 mmHg until the brachial

artery pulses are no longer palpated. Next slowly

rotate the rubber pumping balloon valve and listen for

systolic and diastolic pressure.

Record the results and calculate the MAP value

using the formula: MAP = [Pressure System + 2

(Diastole)]: 3ROT measurement work procedures.

Let the pregnant mother to get into bed and direct the

mother to sleep on her left side and relax for 15

minutes. Ensuring that sphygmomanometer numbers

are visible and the examiner's position must also be

comfortable. Attach a cuff to the left arm of a pregnant

woman with a pipe parallel to the brachial artery.

Ensure that the pulse is in the brachial artery and start

pumping until the pulse is not palpable and mark the

pressure obtained. Put down the stethoscope bell

above the brachial artery. Turn the valve clockwise,

until the valve on the rubber pump is tightly closed.

The cuff is pumped to a pressure of 30 mmHg until

the brachial artery pulses are no longer palpated. Next

slowly rotate the rubber pumping balloon valve and

listen for systolic and diastolic pressure.

Record the results of the left tilted blood pressure

measurement. Let pregnant women to change

sleeping position to the supine position and be relaxed

for 15 minutes. Ensure that the pulse is in the brachial

artery and start pumping until the pulse is not palpable

and mark the pressure obtained. Put down the

stethoscope bell above the brachial artery. Turn the

valve clockwise, until the valve on the rubber pump is

tightly closed. The cuff is pumped to a pressure of 30

mmHg until the brachial artery pulses are no longer

palpated. Next slowly rotate the rubber pumping

balloon valve and listen for systolic and diastolic

pressure. Invite and accompany the mother to get

down from the bed. Recording supine blood pressure

measurement results.. Calculate and record the

diastole blood pressure difference in the left tilt

position with supine position.

Data collection was carried out after obtaining

permission from the research location and the

Research Ethics Commission.

The researcher met with related parties at the

research location through the following procedure.

Determine the subject based on inclusion and

exclusion criteria. Introduce yourself and explain

research covering the objectives, rights and

obligations of the subject as well as the benefits of

research to the subject. Provide an informed consent

sheet to be signed by the subject, if the subject is

willing to participate in the study. Explained the

procedure of the series of checks to be carried out.

Measuring the blood pressure of the subject by using

the spigmomanometer 3 times, ie when in a sitting

position, sleep on your left side after that 15 minutes

later when the supine sleep position. Conduct direct

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interviews related to stress experienced by the subject.

Enter into a repeat examination meeting contract and

conduct MAP and ROT examinations at 28 and 32

weeks' gestation. Record all data on the observation

sheets. Data processing is carried out with the SPSS

(Statistical Product and Service) program through the

stages of editing, coding, data entry, data cleaning.

This analysis described the data in the form of a

categorical table. The data which have processed will

be presented in tabular and narrative form. The Data

that have been got by cross sectional and prospective

cohort used Chi-Square test analysis to see the

relationship of stress, MAP and ROT with pregnancy

hypertension. The strength of the data relationship

obtained by cross sectional is known based on the

calculation of the association size of the Odds Ratio

(OR) and the strength of the data relationship obtained

through the prospective cohort approach is known

based on the calculation of Relative Risk (RR). If OR

/ RR is equal to 1 it means that there is no relationship

between the independent variable and the dependent

variable. If OR / RR is more than 1, it means that there

is a relationship between the independent variable and

the dependent risk factor. If OR / RR is smaller than

1, it means that there is a relationship between the

independent variable and the dependent dependent

which is protective for the effect. In addition to the

OR / RR value, we also pay attention to the value of

the confidence interval (CI) and the p-value. If CI

accross number 1, the OR / RR value is not

significant.

3 RESULT AND DISCUSSIONS

Figure 1 showed that based on work status, education,

age, household income, wife's salary, husband's

salary, household members, home ownership status,

history of abortion, parity of pregnancy plans and

pregnancy spacing there were no significant

differences between groups of normal pregnant

women with the hypertension group in pregnancy as

seen from the frequency distribution graph based on

the characteristics of the respondents. So it can be

concluded that the study sample was normally

distributed and was homogeneous.

Figure 1: Frequency distribution based on respondent Characteristics.

Table 1 showed a significant difference in the history

of preeclampsia and eclampsia with a value of p =

0.001; OR = 10,286; 95% CI 2,209-47,9. That is,

pregnant women who have a history of PE / E have a

tendency to experience hypertension at 27 weeks

gestation by 10 times compared to pregnant women

who have no history of PE / E.

Normal Pregancyhypertension

Stress, Mean Arterial Pressure, and Roll over Tests as a Predictor of Pregnancy Hypertension

123

Table 1: The relationship of obstetric history with hypertension at 27 weeks gestation.

Variable

Normal Hypertension

(95% CI)

N (%) N (%)

PE History

Doesn’t exist 47 56,6 36 43,4

0,001

10,286

(2,209–47,901)

There’s

17,6 14 82,4

Abortion History

No 44 51,8 41 48,2

0,575

1,61

(0,527 – 4,920) There’s

Paritas

Primi 17 47,2 19 52,8

0,835

0,841

(0,371 – 1,904)

Multi 33 51,6 31 48,4

Planning of

pregnant

Yes 44 48,9 46 51,1

0,739

0,638

(0,168 – 2,413)

Pregnancy

Distance

≥ 24 Months 40 47,6 44 52,4

0,413

0,545

(0,182 – 1,637)

< 24 Months 10 62,5

37,5

Based on the analysis of the data, the researchers

concluded that although a history of abortion, parity,

pregnancy planning and pregnancy spacing does not

have an influence or relationship to the incidence of

hypertension in pregnancy, but if the pregnant woman

has a history of preeclampsia / eclampsia, it is likely

that the mother will fall into a condition of

hypertension in her pregnancy. Table 2 showed a

significant difference in the history of preeclampsia

and eclampsia with a value of p = 0.026; RR = 1,667;

95% CI 1,223-2,272. That is, pregnant women who

have a history of PE / E have a tendency to experience

hypertension at 32 weeks gestation by 2 times

compared to pregnant women who have no history of

PE / E.

Table 2. Analysis of the relationship of obstetric history with the incidence of hypertension at 32 weeks gestation.

Variabel

Normal Hypertension

(95% CI)

N (%) N (%)

0,026

1,667

(1,223 – 2,272)

No History PE 42 50,6 41 49,4

Exist 3 17,6 14 82,4

History of

Abortion

43 45 57

0,604

0,836

(0,513 – 1,362)

Exist

52,4 10 47,6

Parity

Primi

47,2

52,8

0,900

1,066

(0,731 – 1,554)

Multi

43,8 36 56,3

Pregnancy plan

Yes 39 43,3 51 56,7

0,503

0,706

(0,323 – 1,54)

No 6 60 4 40

Pregnancy

Distance

≥ 24 Months 34 40,5 50 59,5

0,503

0,525

(0,249–1,109)

< 24Months 11 68,8 5 31,3

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Table 3 showed that minor stress has a statistically

significant relationship between the normal tension

group and the hypertension group at 27 weeks'

gestation. Pregnant women who got experience minor

stress have a tendency to experience hypertension by

4 times compared to pregnant women who are not

stressed. This is because psychological stress can

activate the hypothalamic-pituitary adrenal (HPA)

axis, which in turn will increase corticosteroid and

ketocolamin levels in the blood, this hormone will

suppress the production of the adrenal glands and

cause vasoconstriction of blood vessels. In this

analysis just normal and minor stress categories which

tested, because there were no samples that

experienced moderate or severe stress (scores above

25).

Table 3: Relationship between stress and the incidence of hypertension at 27 weeks gestation.

Category

Normal Tension Hypertension

(95% CI)

N (%) N (%)

Negative 47 68,1 22 31,9

0,001

19,939

(5,468-72,714)

Positive 3 9,7 28 90,3

Table 8 showed that the roll over test statistically has

a significant relationship between the normal tension

group and the hypertension group at 32 weeks'

gestation. Pregnant women with a positive ROT at 27

weeks gestation and a positive ROT at 28 weeks

gestation are at risk of having hypertension in

pregnancy by 2 times and 3 times compared to

pregnant women with a negative ROT at 27 and 28

weeks gestation. Seen from pregnant women who

have a positive ROT at 32 weeks gestational age tend

to experience hypertension 98 times compared to

pregnant women who have a negative ROT.

Table 8: Relationship of ROT with the incident of hypertension at 32 weeks gestation.

Variabel

Normal Tension Hypertension

(95% CI)

N (%) N (%)

ROT 27 week

0,001

1,996

(1,453 – 2,740)

Negative 40 58 29 42

Positive 5 16,1 26 83,9

ROT 28 week

Negative 39 72,2 15 27,8

0,001

3,13

(2,007 – 4,882)

Positive 6 13 40 87

ROT 32 week

Negative 44 72,1

27,9

0,001

98,353

(12,498 – 773,965)

Positive

2,6

97,4

There is a profound effect between maternal

position on the hemodynamic profile in the mother

and fetus. In the supine position the pressure from

the Vena Cava Inferior (VCI) causes a decrease in

venous return to the heart and results in decreased

stroke volume and cardiac output. Turned around

from lateral to supine position can result in a

decrease in cardiac output by 25%, causing

disruption of uteroplacental blood flow (Sherwood,

2014)

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

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4 CONCLUSION

The results of the research concluded that stress, MAP

and ROT are associated with the incidence of

hypertension in pregnancy. Stress, MAP and ROT can

be used as predictors of pregnancy hypertension

(gestational ages 27 and 32 weeks).

ACKNOWLEDGEMENT

The researcher would like to thank all those who

helped during the research process and all the staff of

the Health Institute of Medistra Lubuk Pakam and

GrandMed Hospital.

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