Roll-over test

GEORGE W. MARSHALL, M.D.

ROBERT L. NEWMAN, M.D.

Kansas Ci$ Missouri

One hundred randomly selected nulliparous, normotensive women were subjected to the
roll-over test between 28 and 32 weeks’ gestation. Twenty-&e women had a positive test.
Thirteen of those 25 women developed /rre-eclampsia requiring magnesium sulfate
therapy. Eight had transient hypertension during labor requiring no therapy. Four had
no evidence of hypertension during pregnancy. A false-positive rate for the 25 women
with a positive roll-over test was 16 per cent. Seventy-five women had a negative
roll-over test. Sixty-eight of those women had no evidence of hypertension of pregnancy.
Seven had evidence of transient hypertension during tabor requiring no therapy. A
false-negative test was present in IO per cent of the 75 patients with a negative roll-over
test. In no case did a patient with a negative test develop pre-eclampsia. The roll-over test
is recommended as a routine test for every pregnant patient between 28 and 32 weeks’
gestation for the early diagnosis of hypertension of pregnancy. (AM. J. OBSTET.
GYNECOL. 127: 623, 1977.)

THE ETIOLOGY of hypertension induced by preg- utilized from the St. Luke’s Hospital Obstetric Clinic.
nancy is unknown. Recently, several papers have None of the patients had a previous history of renal
suggested that the possible mechanism for hyperten- disease, hypertension, heart disease, or diabetes. All
sion may involve factors that regulate the uteroplacen- patients were followed in the Obstetric Clinic and
tal blood flow. ‘-I3 The uteroplacental unit represents a examined at regular intervals. All patients were al-
system in which blood flow is highly critical. It would lowed a diet of their choice with no alterations of
seem logical to search for a self-regulatory hemo- sodium intake.
dynamic mechanism such as that demonstrated in Diuretics were not prescribed for any patient in the
the renin-angiotensin-prostaglandin regulatory mecha- study during the prenatal course.
nism in the kidney. i, ‘-* The purpose of the present The roll-over test was performed between 28 and 32
investigation was to: (1) ascertain whether changing weeks’ gestation in the following manner: To establish
a patient from the left lateral recumbent position to a baseline diastolic blood pressure, the patient was
the supine position would cause an elevation in the placed in the left lateral recumbent position and the
blood pressure of a patient susceptible to developing blood pressure was measured at 5 minutes and again at
hypertension of pregnancy and (2) attempt to substan- 15 minutes. The subject was then turned to the supine
tiate the work of Gant and associates2-4 in predicting position and the blood pressure was measured im-
the development of pregnancy-induced hypertension. mediately and 5 minutes later with the patient still
supine. An increase in diastolic pressure of 20 mm. Hg
Materials and methods or more was considered a positive roll-over test. Aus-
One hundred randomly selected normal primigravid cultatory blood pressure measurements utilizing the
women between 28 and 32 weeks’ gestation were onset of the first (systolic) and fifth (diastolic) sounds of
Korotkoff were used when recording the blood pres-
sure. The test results were kept in a separate record file
From St. Luke’s Hospital.
which was not opened until after the patient had been
Supported by the St. Luke’s Hospital Foundation for
Medical Education and Research. discharged from the hospital following delivery. The
attendants caring for the patient during labor, deliv-
Received for publication May Il. 1976.
ery, and the postpartum period did not know the re-
Accepted October 13, 1976.
sults of the roll-over test.
Reprint requests: Dr. G. W. Marshall, St. Luke’s Hospital
of Kansas City, Wornull Rd. at 44th, Kansas City, The definition of pregnancy-induced hypertension
Missouri 641 II. used in this study was that used by Cant and as-

623
624 Marshall and Newman

Table I. Positive roll-over test developed cc lampsia. Eight patients developed tl’atl-
I sient hvpertension during labor and delivery and I(:-
I .L’O
I quired no magnesium sulfate or ~~ntihypertensivr
Required magnesium sulfate 13 medication. Four patients with a positive roll-over trst
Transient hvoertension 8
4 had no complications of hypertension throughout thei
No hypert&&n of pregnancy
Total 25 prenatal course, labor, delivery, and the postpartum
period. One of those patients was delivered at 34
weeks’ gestation and that might be the explanation 101
Table II. Negative roll-over test the false-positive test. The false-positive rate for the
roll-over lest was 16 per cent (Table III).
I No. Table II summarizes the results for 68 of the 53
No hypertension of pregnancy 68 patients who had a negative roll-over test. In no case
Transient hypertension 7 did any patient develop prc-eclampsia. Seven patients
Total 75 with negative roll-over tests developed transient hyper-
tension. None of. the patients required magnesium sul-
fate or antihypertensive medication. Three patients
Table III. No. of roll-over tests
with a negative roll-over test were delivered bef’ore YG
No. weeks’ gestation. A false-negative test was present in 10
Total No. 100 per cent of’ the 75 cases (Table III) (chi square
(1) = 51.85. P < 0.001).
Positive test 25
False positive 16%
Comment and conclusion
Negative test 75
False negative 10% In normal pregnancies there is an increased resis-
tance to infused angiotensin 11 and increased produc-
tion of prostaglandin F..‘-‘. ‘“, ‘I. ” In pregnancies
sociates.‘-’ Pregnancy-induced hypertension is defined complicated by pregnancy-induced hypertension,
as acute hypertension developing in a primigravida there is no increased resistance to angiotensin II but
whose blood pressure was normal prior to the third there is, in fact. a loss of resistance and development of
trimester of pregnancy. The blood pressure is persis- enhanced vascular sensitivity and a decrease in prosta-
tently elevated to 140/90 mm. Hg or greater and con- glandin E production.‘-‘, I”. ‘la ‘-1
stitutes an increase in the diastolic blood pressure of 20 Weinberger and associates” demonstrated an in-
mm. Hg or greater above previous levels during crease in plasma renin activity in normal term preg-
pregnancy. Eclampsia is defined as the syndrome nant women after 30 minutes or more in the supine
of pregnancy-induced hypertension complicated by position. Gant and associates’ failed to demonstrate ;I
grand ma1 seizures that are not the result of some difference in plasma renin activity in patients who were
complicating neurological disease. Pregnancy-induced supine for less than 15 minutes. Since Gant and as-
hypertension was further subdivided in this study into sociates observed a pressor response within 5 minutes
two groups: (1) pre-eclampsia requiring magnesium after rolling the patient to the supine position, it ap-
sulfate therapy and (2) transient hypertension. Tran- pears unlikely that the supine pressor response can 1,~
sient hypertension according to Hellman and Prit- explained on the basis of increased secretion of renin.
chard5 is a form of pregnancy-induced hypertension Whether the defect is in the prostaglandin production.
which develops during labor or within the first 24 loss of response to prostaglandin, renin-angiotensin
hours post partum and disappears within 10 days after changes. or a combination of events has not been
delivery. Generalized edema and proteinuria are ab- proved.
sent and no antihypertensive therapy is required. When a pregnant patient was changed from the left
lateral recumbent position to the supine position IK-
Results tween 28 and 32 weeks’ gestation, the roll-over test ac-
In Table I, the results are summarized for 25 women curately predicted the future presence or absence of
who had positive roll-over tests at 28 to 32 weeks’ gesta- hypertension in 89 of 100 women studied. However. it
tion. Thirteen of those 25 patients developed pre- seems more important to state that 90 per cent of the
eclampsia requiring magnesium sulfate therapy during women having a negative roll-over test remained nor-
labor, delivery. and the postpartum period. No patient motensive. whereas 84 per cent of those with a positive
Volume 127 Roll-over test 625
Number 6

roll-over test developed pregnancy-induced hyperten- test is recommended as a routine test for pregnant pa-
sion. The present study demonstrates results similar to tients between 28 and 32 weeks’ gestation for the early
those of Gant and associates, therefore the roll-over diagnosis of hypertension of pregnancy.

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