DOI

1056  Indian Journal of Public Health Research & Development, January 2020, Vol. 11,Number:
No. 01 10.37506/v11/i1/2020/ijphrd/193977

The Role of Mean Arterial Pressure (MAP) Roll Over Test

(ROT) and Body Mass Index (BMI) in Preeclampsia
Screening in Indonesia

Dwi Putri Rahayu Tampubolon1, Lilik Herawati2, Nursalam3, Ernawati4

1Student in Midwifwery Program, 2Physiology Department Faculty of Medicine, 3Faculty of Nursing,
4
Obstetrics and Gynecology Department Faculty of Medicine Universitas Airlangga

Abstract
Objective: To evaluate the role of MAP, ROT, and BMI in preeclampsia screening in low resources setting.

Method and Material: This is a retrospective study conducted on 1011 pregnant women who had an
antenatal care at Public Health Center in Indonesia. Data taken from public health medical report. The
sample groups were 45 preeclampsia patients who have had complete screening of MAP, ROT and BMI.
The control groups were normal pregnant women who attained same inclusion criteria.

Results: The pre eclampsia group had positif MAP and obesity result respectively 95.6% and 40% of
patients, but in control group only had 40% and 11.1% of patient have positive MAP and obesity respectively.
Statistical test illustrates a significant association between MAP and BMI screening with the incidence of
preeclampsia (p 0.0001, OR = 32.250 and p 0.002, OR = 5.333).Whereas positive ROT showed in 40%
PE groups and 57.8% control group. There is no association between ROT screening and the incidence of
preeclampsia (p 0.092).

Conclusion: MAP and BMI can be used as baseline screening tools of preeclampsia in low resources setting.
But ROT is not associated with the incidence of preeclampsia.

Keywords:  Preeclampsia Screening, MAP, ROT, BMI.

Introduction of pregnancy is important to identify women who are at

risk of developing PE so that early enough prevention
Preeclampsia (PE) is a complex medical disorder,
treatment could start to prevent or reduce the frequency
who is is responsible for neonatal and maternal deaths
of its occurrence.
worldwide. It is also becomes the biggest cause of high
Maternal Mortality Rate (MMR) in Surabaya Indonesia Preeclampsia screening vary from clinical to
from 2013‑20171. Accurate prediction and aggressive biomolecular level depend on the resources availability.
prevention allowed to elude this pregnancy complication. In low and middle income countries where resources are
Effective screening to predict PE in the first trimester limited, variations of the first‑trimester combined test
can be considered but difficult to reached. The baseline
test which is possible to do are combine of maternal risk
factors with Mean Arterial Pressure (MAP) and Roll
Corresponding Author:
over Test (ROT). In the absence of other biomarker(s),
Ernawati
risk calculation can still be done but the detection rates
Obstetrics and Gynecology Department Faculty of
will be reduced .
Medicine, Universitas Airlangga Surabaya, Jawa Timur,
Indonesia MAP and ROT are a method to describe
Phone : +6281232850261 hemodynamic conditions in patients with preeclampsia.
email: ernawati.spog@gmail.com ROT is not a perfect predictor, but it still have advantages
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01  1057
to use in populations with high PIH associated maternal medical report. The sample groups were 45 preeclampsia
and perinatal mortality, mostly in low resources setting2. patient during that period time who fulfilled inclusion
It has been used in many contries but some literature criteria: patients in the first and second trimesters who
shows that ROT is not related to the incidence of have had complete screening of MAP, ROT and BMI.
preeclampsia3. The purpose of this study is to determine The control groups were normal pregnant women
the effectiveness of preeclampsia screening (MAP, ROT, who attained same inclusion criteria. It was takenby
and BMI) to the incidence of preeclampsia in Indonesia. consecutive sampling. Positive result noted if MAP is
> 90 mmHg. ROT classified as positive result if there
Material and Method were different of diastolic pressure between supine and
This is a retrospective study conducted on 1011 lateral position more than 15 mmHg3. The values on
pregnant women who performed an antenatal care at BMI screening classified as obesity if the result >30.The
Sidotopo Wetan Public Health Center (Puskesmas samples were traced retrospectively to see the MAP,
Sidotopo Wetan), Surabaya, Indonesia from October ROT and BMI screening history and demographic data.
2017 to October 2018. Et Data taken from public health

Finding:
Table 1: Demographic Characteristics

PE group Control group Total

Age (Year)
n (%) n (%) n (%)
< 20 0 (0) 3 (6.7) 3 (3.3)
20‑35 37 (82) 38 (84.4) 75 (83.3)
> 35 8 (18) 4 (8.9) 12 (13.3)
Parity
Primi 9 (20) 13 (28.9) 22 (24.4)
Multips 36 (80) 32 (71.1) 68 (75.6)
Risk Factor
Anemia 3 (6.7) 0 (0) 3 (3.3)
Gestational diabetes 5 (11.1) 2 (4.4) 7 (7.8)
History of Preeclampsia 1 (2.2) 0 (0) 1 (1.1)
Obesity 16 (35.6) 5 (11.1) 21 (23.3)
Tuberculosis 2 (4.4) 0 (0) 2 (2.22)
HbsAg (+) 1 (2.2) 0 (0) 1 (1.1)
History of IUFD 1 (2.2) 0 (0) 1 (1.1)
Under nutrition 1 (2.2) 6 (13.3) 7 (7.8)

Baseline demographics of study participants are nulips. Obesity has the highest rank in PE risk factor in
presented in Table 1. Most pregnant women in both this study. It counts a percentage of 35.6% obesity cases.
groups are in reproductive ages. It also worked on parity Followed by Gestational diabetes and anemia.
data, which is multips showed have larger number than

Table 2: MAP, ROT, BMI and the incidence of preeclampsia

PE Group Control Group Total

Screening P OR
n (%) n (%) n (%)
MAP (‑) 2 (4.4) 27 (60) 29 (32.2)
0.0001 32.250
MAP (+) 43 (95.6) 18 (40) 61 (67.8)
ROT (‑) 27 (60) 19 (42.2) 46 (51.1)
0,092 ‑
ROT (+) 18 (40) 26 (57.8) 44 (48.9)
Obesity (‑) 27 (60) 40 (88.9) 67 (74.4)
0,002 5.333
Obesity (+) 18 (40) 5 (11.1) 23 (25.6)
1058  Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
The MAP test in this study pointed out that 95.6% on MAP measurement of more than 9000 pregnancies
preeclampsia samples have a value of positive MAP, at 11–13 weeks of gestation compared the screening
while only 40% samples of control groups have a positive using systolic blood pressure, diastolic blood pressure,
MAP. This study in accordance with another study by and MAP.MAP performed best as a marker, with an
Gasse et al in 2017, which is showed that first‑trimester increasing of detection rate for early onset PE from
MAP is a strong predictor of gestational hypertension 47% (based on maternal factors alone) to 76% (based
and preeclampsia in nulliparous women4. on MAP and combination of maternal factors) at 10%
false positive rate8.MAP screening in first‑trimester
Table 2 also showed that 60% preeclampsia is a strong predictor of gestational hypertension and
patients have negative ROT screening and are inversely preeclampsia9,10.
proportional to control group that most of them have
positive ROTscreening with p value 0.092 which means The value of roll‑over test has advantages in its
that there is no association between ROT measurement simplicity. It requires simple equipment and no special
and the incidence of preeclampsia. skill. ROT is performed by positioning the patient in a
lateral state and then a blood pressure measurement is
The results of BMI measurement and the incidence made until there is no change in blood pressure. Then,
of preeclampsia in this study showed that 40% the tension is measured in the supine position and the
preeclampsia patient are obese but only 11.1% control tension results are recorded again.
group patient recorded obese. Statistical analysis noted
p value 0.002 which could be explained that there Some study showed roll‑over test are highly variable
is a relationship between BMI and the incidence of among different investigators and also inconsistent
preeclampsia. reproducibility in the same patient. Literature review
reveals sensitivities varying between 0 to 93% and
Discussion specificities between 54 – 91% and false positive results
Baseline data in this study discordant with the theory up to 90%. Walia et all study in 2015 also reported
of preeclampsia and other study which is reproductive roll‑over test performed at 24 weeks had negative in all
ages and multips are low risk group to have hypertension study cases. So, it is clear that ROT has no role as early
in pregnancy. It could be explained that reproductive age predictive in preeclampsia3.
in this study has preeclampsia risk factor ie gestational The relationship between preeclampsia and obesity
diabetes, obesity, history of preeclampsia and infection. has been greatly studied. Obesity prevalence has
Another study from Indonesia also pictured that more increased over 25 years it is similar to preeclampsia
than 50% patients who experienced preeclampsia are prevalence. This study showed obesity has correlation
between 20 to 35 years old5.Parous women without with incidence of PE. It revealed OR 5.3 in obesity cases
prior history of PE have lower risk of PE; however, this compare non obesity cases.
protective effect will change when they have different
conception partner6. This data support substantial evidence which is
show that obesity (BMI ≥30 kg/m2) confers a higher risk
MAP test showed strong relationship with for PE10,11,12. Obesity also state as meta inflammation,
incidence of preeclampsia in this study, it revealed odd associated with chronic stress and inflammatory response.
ratio 32.25. This data inline with Poon study in 2008 The inflammatory response was found to increase
which reported first study on MAP measurement using in obese women and contribute to vascular targets
validated automated blood pressure devices according and vascular changes induce endothelial dysfunction
to a standardized protocol and maternal variables in and placental ischemia in turn exaggerated maternal
11+0 to 13+6 weeks pregnancy can predict PE.Maternal inflammatory response and induce preeclampsia13,14,15.
blood pressure was measured in 5590 singleton pregnant
women. the detection ratesfor PE, at 10% false positive This study in line with FIGO guideline on
rate, were 38% and 63%, respectively for MAP alone preeclampsia screening where state that if it is not
and in combination with maternal history7. possible to measure biomarker (PLGF) and/or uterine
artery doppler, combination of maternal risk factor and
MAP is a reflection of hemodynamic perfusion MAP has advantages than maternal risk factor alone.
pressure from vital organs. Another follow‑up study Simple method to measure in Public health will increase
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01  1059
awareness, access, affordability, and acceptance prenatal weeks in the prediction of preeclampsia.
screening of preeclampsia16. Hypertension. 2008;51(4):1027-33
8. Poon LC, Kametas NA, Valencia C, Chelemen
Conclusion T, Nicolaides KH. Hypertensive disorders in
MAP and BMI can be used as baseline screening pregnancy: Screening by systolic diastolic and
tools of preeclampsia in low resources setting with OR mean arterial pressure at 11-13 weeks. Hypertens
= 32.250 and 5.333. But ROT is not associated with the Pregnancy. 2011;30:93–107
incidence of preeclampsia. 9. Gallo, D., Poon, LC., Fernandez, Wright, D.,
Nicolaides, KH. Prediction of Preeclampsia by
Conflict of Interest: None
Mean Arterial Pressure at 11–13 and 20–24 Weeks’
Funding: Self‑funding. Gestation. Fetal Diagnosis Therapy, 2014;36:28‑37
10. Liu L, Hong Z, Zhang L. Associations of
Ethical Clearance: Approved by the Ethics prepregnancy body mass index and gestational
Committee Medical Faculty Universitas Airlangga weight gain with pregnancy outcomes in nulliparous
women delivering single live babies. Sci Rep.
References 2015;5:12863.
1. Surabaya Health office 5 year report, 2017. 11. Rahman MM, Abe SK, Kanda M, et al. Maternal
Unpublished data body mass index and risk of birth and maternal
2. Narvaez, M, Weigel, M.M, Felix, A, Jaramilo, health outcomes in low and middle income
L P. The clinical utility of the roll-over test in countries: A systematic review and meta-analysis.
predicting pregnancy-induced hypertension in a Obes Rev. 2015;16:758–770.
high-risk Andean population. International Journal 12. Wei Y-M, Yang H-X, Zhu W-W, et al. Risk of
of gynecology& Obstetrics. 1990;vol 31:1; 9-14 adverse pregnancy outcomes stratified for pre-
3. Walia, D and Gupta. Comparison between roll-over pregnancy body mass index. J Matern Fetal
test and placental localization for early prediction Neonatal Med. 2016;29:2205–2209.
of preeclampsia. 2015; DOI: 10.18203/2320-1770. 13. Gregor MF, Hotamisligil GS. Inflammatory
ijrcog20150784 mechanisms in obesity. Annu Rev Immunol.
4. Gasse C., Boutin A., Cote M., Chaillet N., Bujold E., 2011;29:415–445.
and Demers S. First-trimester mean arterial blood 14. Spradley FT, Palei AC, Granger JP. Immune
pressure and the risk of preeclampsia: The Great mechanisms linking obe- sity and preeclampsia.
Obstetrical Syndromes (GOS) study.Pregnancy Biomolecules. 2015;5:3142–3176.
Hypertens,2017.;12:178-182. doi: 10.1016

15. Reslan, O. M. and Khalil, R. A. Molecular And
5. Ernawati, Erry Gumilar, Kuntoro, Joewono Vascular Targets In The Pathogenesis And
Soeroso & Gus Dekker. Expectant management of Management Of The Hypertension Associated With
preterm preeclampsia in Indonesia and the role of Preeclampsia. Cardiovascular & hematological
steroids, The Journal of Maternal-Fetal & Neonatal agents in medicinal chemistry. 2010; 8(4), pp. 204–
Medicine. 2016;29(11):1736-40. 26. doi: 10.2174/187152510792481234.
6. Robillard PY, Hulsey TC, Alexander GR, Keenan 16. Poon. L, Shennan. A, Hyeet. J.A, Kapur. A, Hadar.
A, de Caunes F, Papiernik E. Paternity patterns E, et al. The International Federation of Gynecology
and risk of preeclampsia in the last pregnancy in and Obstetrics (FIGO) initiative on pre-eclampsia:
multiparae. J ReprodImmunol. 1993;24:1–12. A pragmatic guide for first-trimester screening and
7. Poon, LC., Kameta NA., Valencia C., Nicolaides prevention. Int J Gynecol Obstet, 2019; 145 (Suppl.
KH. Mean arterial pressure at 11(+0) to 13(+6) 1): 1–33