SÃO PAULO
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~,
Luiz F rancisco M arcopito
R oll-over test in prim igravidae attending a
public prim ary care service
Division of Epidemiology,
Federal University of São Paulo, Brazil
O bjective:T o determine the roll-over test (ROT) performance in predicting pregnancy-induced hypertension (PIH) in primigravidae aged
15-29 years in a public primary care service. M ethod: Prospective cohort study enrolling 369 consecutive and initially normotensive
primigravidae. The ROT was applied within 28-32 weeks of pregnancy. PIH was defined as diastolic blood pressure (DBP) 90 mm Hg or systolic blood pressure (SBP) 140 mm Hg, or a rise in DBP 15 mm Hg or a rise in SBP 30 mm Hg. The ROT prognostic properties
were calculated, and a receiver operating characteristic (ROG) curve was constructed. R esults: For the 20 mm Hg cutoff point,
sensitivity was 20% and specificity was 93%. Positive and negative predictive values were, respectively, 23% and 92%, for a PIH
cumulative incidence of 9.5%. W ith other cutoff points, the ROG curve showed a poor discriminatory value of the test. C oncliJsion:
The ROT was not useful for predicting PIH in a primary prenatal care setting.
Uniterms: Pregnancy. Pregnancy-induced hypertension. Toxemia. Pre-eclampsia. RolI-Over Test.
INTROOUCTION
H
y p erten sio n w h ich co m p licates p reg n an cy is am ajo r cau se o f p rem atu rity an d p erin atal
m o rtaIity . IA n y Iarg e u n seIected g ro u p o f p reg n an t
w o m en w ith raised b Io o d p ressu re w ill co n tain in d iv id u aIs
w h o se h y p erten sio n an ted ates th e p reg n an cy , th o se w h o se
b Io o d p ressu re b eg an to rise after th e en d o f th e seco n d
trim ester (p reg n an cy -in d u ced h y p erten sio n - P IH ), an d a
few w ith p re-ex istin g h y p erten sio n ex acerb ated b y th e
p reg n an cy . It is reco g n ized th at p rim ig rav id ae are at h ig h est
risk o fP IH .2
In m o st p arts o f th e w o rld , p ren atal care serv ices, w h en
accessib le, h av e th e m o st p ro fo u n d effect o n th e
A dress for correspondence:
Luiz F rancisco M arcopito R ua P edro de T oledo, 675
S ão P aulo/S P - B rasil - C E P 04039-032
co n seq u en ces o f h y p erten sio n in p reg n an cy , b u t n o t in its
p rev en tio n . If th e ro ll-o v er test (R O T ), p u b lish ed b y G an t
et aI.3in 1 9 7 4 an d still tau g h t in m ed icaI sch o o ls, is in fact
accu rate, it co u ld b e u sefu l fo r id en tify in g h ig h er risk g ro u p s
o f p rim ig rav id ae, w h o w o u ld d eserv e sp ecial atten tio n .
T h is p ro sp ectiv e stu d y w as th erefo re aim ed at
d eterm in in g th e v aIu e o f th e R O T in p red ictin g P IH
d ev elo p m en t in p rim ig rav id ae ag ed 1 5 -2 9 y ears Iiv in g in th e
eastem reg io n o f G reater S ao P au lo , B razil, a 1 0 w -in co m e
u rb an area, w h o atten d ed a p rim ary p ren atal care p u b lic serv ice
(L eo n o r M en d es d e B arro s M atern ity H o sp ital).
PARTICIPANTS ANO METHOOS
T h e in cIu sio n cri teria w ere as fo llo w s: a) sp o n tan eo u s
d em an d fo r ro u tin e p ren atal assistan ce in th e serv ice w h ere
th e stu d y w as b ased ; b ) rep o rtin g b ein g p rim ig rav id a at th e
MARCOPITO, L.F. - Roll-over test in primigravidae attending a public primary care service
1 5 3 4
tim e o f re g istra tio n ; c ) 1 5 -2 9 y e a rs o ld ; a n d d ) n o rm o te n siv e (b lo o d p re ssu re lo w e r th a n 1 4 0 /9 0 m m H g b e fo re th e 2 4 th w e e k o f p re g n a llc y ) w ith o u t th e u se o f a n ti-h y p e rte n siv e d ru g s.
T h e e x c lu sio n c rite ria (a n d th e re sp e c tiv e n u m b e rs e x c lu d e d b y e a c h c rite rio n ) w e re a s fo lIo w s: a ) in th e first c o n ta c t, e x p e c ta tio n o f m o v in g to a n u n k n o w n "a d d re ss (7 ); b ) c o n tin u e d in a b ility to g iv e a p re c ise h o m e a d d re ss a t th e se c o n d c o n ta c t (1 0 ); c ) m isc a rria g e b e fo re th e 2 4 th w e e k o f p re g n a n c y (5 ); d ) d e te rm in a tio n , th ro u g h fu rth e r c o n ta c t, th a t th e w o m a n w a s e ith e r n o t a p rim ig ra v id a (4 ) o r n o t p re g n a n t (3 ); e ) su ffe re d c o n g e n ita l v a sc u la r d ise a se (1 ); o r f) m a d e re g u la r u se o f a sp irin o r d ru g s k n o w n a s v a so a c tiv e s (z e ro ). O u t o f 4 2 2 p rim ig ra v id a e c o n sid e re d e lig ib le , 3 9 4 w e re su b m itte d to R O T .
L o ss d u rin g fo lIo w -u p w a s m in im iz e d b y sp e c ia l e ffo rts a im e d a t th o se (6 8 % ) w h o m isse d a t le a st o n e a p p o in tm e n t: 4 6 te le p h o n e c a lIs w e re m a d e , 7 3 1 le tte rs w e re se n t (m a x im u m o fth re e p e r w o m a n )4 , a n d 1 5 1 h o m e v isits w e re p e rfo rm e d (in th e c a se o f n o n -re sp o n se to th e th ird le tte r). T h e se e ffo rts re su lte d in fo lIo w -u p lo sse s o f o n ly 6 .3 % (2 5 p a rtic ip a n ts). A Iso , 3 4 h o sp ita Is h a d to b e v isite d in o rd e r to g e t th e m e d ic a I re c o rd s o f th o se (m o re th a n 5 0 % ) w h o g a v e b irth in h o sp ita Is o th e r th a n th a t w h e re th e stu d y w a s b a se d . A lI th e re m a in in g 3 6 9 w e re fo lIo w e d u p fro m 2 4 w e e k s o f p re g n a n c y u n til o n e m o n th a fte r d e liv e ry .
T h e R O T c o n siste d o f th e sa m e p ro c e d u re p e rfo rm e d b y G a n t e t a I. 3 , e x c e p t th a t th e p a rtic ip a n ts' re sp o n se s to a n g io te n sin II a fte r th e te st w e re n o t e v a lu a te d . A t th e . tim e o f stu d y , e a c h p a rtic ip a n t w a s p la c e d in th e le ft la te ra l
re c u m b e n t p o sitio n , a n d b lo o d p re ssu re m e a su re m e n ts in th e rig h t u p p e r a rm w e re re p e a te d a t fiv e m in u te s in te rv a ls, u n til a c o n sta n t b a se lin e d ia sto lic b lo o d p re ssu re h a d b e e n e sta b lish e d . W h e n th e d ia sto lic b lo o d p re ssu re h a d b e c o m e c o n sta n t, th e su b je c t w a s tu rn e d to th e su p in e p o sitio n a n d th e b lo o d p re ssu re w a s m e a su re d im m e d ia te ly a n d a g a in fiv e m in u te s la te r w h ile th e p a rtic ip a n t w a s stilI su p in e .
T h e R O T w a s c o n d u c te d b y th e sa m e o b se rv e r e v e ry tim e , w h o w a s tra in e d to m e a su re b lo o d p re ssu re w ith th e L o n d o n S c h o o l o f H y g ie n e a n d T ro p ic a l M e d ic in e so u n d ta p e s. A lI th e p a rtic ip a n ts w e re in v ite d to u rin a te b e fo re th e te st. T h e K o ro tk o ff first p h a se w a s ta k e n a s th e sy sto lic b lo o d p re ssu re . T h e d ia sto lic w a s re c o rd e d a s th e K o ro tk o ff fifth p h a se - o r th e fo u rth , if th e fifth p h a se w a s n o t d e te c te d b e fo re th e v a lu e re a c h e d z e ro .
A n in c re a se in d ia sto lic b lo o d p re ssu re o f a t le a st 2 0 m m H g , fro m th e le ft la te ra l to th e su p in e p o sitio n , w a s ta k e n a s a p o sitiv e te st, b u t o th e r c u to ff p o in ts w e re c o n sid e re d in th e a n a ly sis. S e n sitiv ity a n d sp e c ific ity w e re
c a lc u la te d w ith su c h d iffe re n t c u to ff p o in ts, in o rd e r to g e n e ra te a re c e iv e r o p e ra tin g c h a ra c te ristic (R O C ) c u rv e6
•
P IH w a s d e fin e d a s7a d ia sto lic b lo o d p re ssu re (D B P )
o f a t le a st 9 0 m m H g o r a sy sto lic b lo o d p re ssu re (S B P ) o f a t le a st 1 4 0 m m H g , o r a rise in D B P o f a t le a st 1 5 m m H g o r a rise in S B P o f a t le a st 3 0 m m H g . T h e d ia g n o sis o f P IH w a s c o n firm e d w h e n su c h b lo o d p re ssu re re a d in g s w e re o b ta in e d o n a t le a st tw o o c c a sio n s, six h o u rs o r m o re a p a rt. R e g a rd in g th e re v ie w o f m e d ic a I. re c o rd s fro m a ro u n d th e tim e o f d e liv e ry , th e sa m e b lo o d p re ssu re c rite ria w e re a p p lie d , a n d th e m e d ic a I re c o rd re v ie w w a s d o n e b y th e sa m e o b se rv e r, b lin d to th e p re v io u s b lo o d p re ssu re le v e Is o f th e p a rtic ip a n ts.
R E S U L T S
S o m e c h a ra c te ristic s o f th e 3 6 9 p rim ig ra v id a e a n a ly z e d a re sh o w n in T a b le 1 . In th e se w o m e n , th e o v e ra lI risk o fP IH d e v e lo p m e n t w a s 9 .5 % (3 5 /3 6 9 ), w ith th e 9 5 % c o n fid e n c e in te rv a l b e tw e e n 6 .5 % a n d 1 2 .5 % .
T a b le 2 sh o w s th e te st re su lts fo r th e c u to ff p o in t o f ~ D B P ~ 2 0 m m H g . S e n siv ity (7 /3 5 ) w a s 2 0 % , a n d o sp e c ific ity (3 1 1 /3 3 4 ), 9 3 % . P re d ic tiv e v a lu e s (fo r a P IH c u m u la tiv e in c id e n c e o f9 .5 % ) w e re : p o sitiv e (7 /3 0 ), 2 3 % , a n d n e g a tiv e (3 1 1 /3 3 9 ), 9 2 % . T h e se p re d ic tiv e v a lu e s, p a rtic u la rly th e n e g a tiv e , p ro v e d to b e q u ite c lo se to th o se w h ic h w o u ld h a v e b e e n e x p e c te d if th e te sts h a d n o t b e e n p e rfo rm e d .
T a b le 3 sh o w s th e R O T se n sitiv itie s a n d sp e c ific itie s fo r d iffe re n t ~ D B P c u to ff p o in ts. T h o se n u m b e rs w e re u se d to c o n stru c t th e R O C c u rv e e x h ib ite d in th e F ig u re , w h ic h sh o w s th e p o o r R O T p ro g n o stic v a lu e fo r P IH in th e stu d ie d p rim ig ra v id a e .
D IS C U S S IO N
G a n t e t a I.3 o b se rv e d 8 8 % se n sitiv ity (1 5 /1 7 ) a n d 9 5 % sp e c ific ity (2 0 /2 1 ) fo r th e R O T , in a sa m p le w ith P IH o c c u rre n c e o f a lm o st 4 5 % (1 7 /3 8 ), a fig u re fa r d iffe re n t fro m th a t o b se rv e d in u n se le c te d p re g n a n t w o m e n . T h is m a y su g g e st p ro b le m s o f p a rtic ip a n ts' se le c tio n o r u n b lin d e d a sse ssm e n t a n d P IH d ia g n o sis c rite ria .
In th e sa m e w o rk , G a n t e t a I. 3 a lso e v a lu a te d th e re sp o n se to a n g io te n sin II a d m in istra tio n (w ith a n in fu sio n
M A R C O P IT O , L .F . - R o ll- o v e r te s t in p r im ig r a v id a e a tte n d in g a p u b lic p r im a r y c a r e s e r v ic e
1 5 3 5
la b ia 1
S o m e ch a ra cte ristics o f th e 3 6 9 a n a lyze d p rim ig ra vid a e .
la b ia 3
R o lI o ve r te st se n sitivitie s a n d sp e cificitie s fo r p re g n a n cy-in d u ce d h yp e rte n sio n , a cco rd in g to
d iffe re n t cu to ff p o in ts.
*D ifferen ce fro m su p in e to left lateral d iasto lic b lo o d p ressu re, in m m H g .
/ ,/' ,/' ,/' ,/' ,/' ,/' ,/' ,/'
C h a ra cte ristics N u m b e r (% )
A G E (ye a rs)
1 5 -1 9 1 6 1 4 3 .6
2 0 -2 4 1 5 2 4 1 .2
2 5 -2 9 5 6 1 5 .2
E T H N IC G R O U P
W h ite 2 0 6 5 5 .8
A frica n 1 5 9 4 3 .1
A sia n 4 1 .1
E D U C A T IO N (h ig h e st sch o o l g ra d e co m p le te d )
0 -3 4 7 1 2 .7
4 - 7 2 3 2 6 2 .9
8 o r m o re 9 0 2 4 .4
la b ia 2
R o ll-o ve r te st re su lts fo r th e cu to ff p o in t o f A D B P ~ 2 0
m m
H g .P IH * d e ve lo p m e n t
Y e s N o T o ta l
C u to ff p o in t (L \D B P m m H g )*
2 0 o r m o re " 1 4 o r m o re
8 o r m o re 2 o r m o re -4 o r m o re
1 0 0 1 0 0
8 0
~
•..
"S; 6 0
; ; "Ui C 4 0 (1 ) UI 2 0 o 80
S e n sitivity
(% )
( 7 /3 5 ) = 2 0 .0 (1 7 /3 5 )
=
4 8 .6 (2 5 /3 5 )=
6 5 .7 (2 9 /3 5 )=
8 2 .9 (3 4 /3 5 )=
9 7 .1E S P E C IF IC IT Y
6 0 4 0
S p e cificity
(% )
(3 1 1 /3 3 4 )
=
9 3 .1 (1 9 1 /3 3 4 ) = 5 7 .2 (1 2 0 /3 3 4 )=
3 5 .9 ( 3 5 /3 3 4 )=
1 0 .5 ( 5 /3 3 4 )=
1 .52 0
R o ll-o ve r
te st
T o ta l
P o sitive
N e g a tive
7
2 8
3 5
23
3 1 1
3 3 4
30
3 3 9
3 6 9
F ig u re - R e ce ive r o p e ra tin g ch a ra cte ristic cu rve (so lid lin e ) o f th e ro ll-o ve r te st p e rfo rm a n ce in th e p ro g n o sis o f p re g n a n cy-in d u ce d h yp e rte n sio n .
* P reg n an cy -in d u ced h y p erten sio n
p u m p ) a fte r th e R O T , a n d o b se rv e d a h ig h c o rre la tio n w ith th e R O T re su lts. T h is p ro c e d u re , h o w e v e r, w a s n o t te ste d in th e p re se n t stu d y , a s it w o u ld n o t h a v e b e e n fe a sib Ie in a p u b lic p re n a ta I c a re se rv ic e a s c ro w d e d a s th e o n e w h e re th is stu d y w a s b a se d .
T h is tim e -c o n su m in g (a Im o st th irty m in u te s) te st w o u Id c e rta in Iy b e c o n sid e re d fo r p re v e n tiv e p u rp o se s, if it p re se n te d a n a ttra c tiv e p e rfo rm a n c e in d e fin in g
a
h ig h risk g ro u p o f p rim ig ra v id a e fo r d e v e Io p in g P IH . H o w e v e r, a s h a s b e e n sh o w n , th a t w a s n o t th e c a se .M a n y in v e stig a to rs h a v e stu d ie d th e R O T p e rfo rm a n c e in se v e ra I p a rts o f th e w o rId : so m e8
-12 h a v e
re c o m m e n d e d its u se , a n d o th e rsl3
-1 8 h a v e n o L
M e th o d o Io g ic a I d isc re p a n c ie s m a y a c c o u n t fo r su c h a d iv isio n o f o p in io n s: in tw o o f th e se stu d ie slO,1 7 , th e c u
t-o ff p t-o in t o f a p o sitiv e R O T w a s d iffe re n t to i1 D B P ~ 2 0 m m H g ; in tw oI2
,1 6 , d ia g n o sis o f P IH in c Iu d e d c rite ria
o th e r th a n b Io o d p re ssu re o n ly ; in a t Ie a st th re e 8 ,1 4 ,1 8 it
w a s n o t sta te d w h e th e r th e m e d ic a I re c o rd re v ie w e r fo r P IH d ia g n o sis w a s b Iin d to th e R O T re su Its. T h e
re m a in in g1 3
,1 5 still sh o w e d c o n flic tin g re su Its o n th e R O T
p e rfo rm a n c e " , p o ssib Iy b e c a u se o f d iffe rin g P IH d ia g n o sis c rite ria , in sp ite o f b e in g b a se d o n b Io o d p re ssu re o n Iy . N o n e o f th e se stu d ie s w a s c a rrie d o u t in a p rim a ry c a re se ttin g .
C O N C L U S IO N
T h e p o o r p e rfo rm a n c e o f th e R O T in p re d ic tin g fu rth e r P IH d o e s n o t re c o m m e n d its u " se in p rim ig ra v id a e in a p rim a ry p re n a ta I c a re se ttin g .
A C K N O W L E D G E M E N T S
D r. M a rc o p ito w a s fin a n c ia lly su p p o rte d b y F A P E S P 9 5 /4 5 2 8 -0 w h e n th is p a p e r w a s w ritte n .
M A R C O P IT O , L .F . - R o ll-o ve r te st in p rim ig ra vid a e a tte n d in g a p u b lic p rim a ry ca re se rvice
1 5 3 6
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1 2 8 : 1 7 3 -1 7 6 : '
1 6 . B e n e d e tti T J , R e a d J A , M ille r F C . T h e e ffe c t o fh y d ro s ta tic p re s s u re o n th e in te rp re ta tio n o f th e s u p in e p re s s o r te s te J R e p ro d M e d 1 9 8 2 ; 2 7 : 1 6 1 -1 6 4 .
1 7 . H a rtik a in e n R , E rk k o la R . In a d e q u a c y o f ro lIo v e r te s t in p re d ic tin g p re g n a n c y -in d u c e d h y p e rte n s io n . A c ta O b s te t G y n e c S c a n d 1 9 8 2 ; 6 1 : 5 1 1 -5 1 2 .
1 8 . T u n b rid g e R D G , D o n n a i P . P re g n a n c y -a s s o c ia te d h y p e rte n s io n , a c o m p a ris o n o f its p re d ic tio n b y ro lI-o v e r te s t a n d p la s m a n o ra d re n a lin e m e a s u re m e n t in 1 0 0 p rim ig ra v id a e . B r J O b s te t G y n a e c o l1 9 8 3 ; 9 0 : 1 0 2 7 -1 0 3 '2 .
I
