Etiology and management of postpartum hypertension-preeclampsia

Racial Disparity in Postpartum Readmission due to Hypertension among Women with Pregnancy-Associated Hypertension

OBJECTIVE

Postpartum hypertension is a leading cause of readmission in the postpartum period. We aimed to examine the prevalence of racial/ethnic differences in postpartum readmission due to hypertension in women with antepartum pregnancy-associated hypertension.

STUDY DESIGN

This was a multi-institutional retrospective cohort study of all women with antepartum pregnancy-associated hypertension diagnosed prior to initial discharge from January 2009 to December 2016. Antepartum pregnancy-associated hypertension, such as gestational hypertension, preeclampsia (with or without severe features), hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome, and eclampsia was diagnosed based on American College of Obstetricians and Gynecologists Task Force definitions. Women with chronic hypertension and superimposed preeclampsia were excluded. Our primary outcome was postpartum readmission defined as a readmission due to severe hypertension within 6 weeks of postpartum. Risk factors including maternal age, gestational age at admission, insurance, race/ethnicity (self-reported), type of antepartum pregnancy-associated hypertension, marital status, body mass index (kg/m²), diabetes (gestational or pregestational), use of antihypertensive medications, mode of delivery, and postpartum day 1 systolic blood pressure levels were examined. Multivariable logistic regression models were performed to calculate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).

RESULTS

Of 4,317 women with pregnancy-associated hypertension before initial discharge, 66 (1.5%) had postpartum readmission due to hypertension. Risk factors associated with postpartum readmission due to hypertension included older maternal age (aOR = 1.44; 95% CI: 1.20-1.73 for every 5 year increase) and non-Hispanic black race (aOR = 2.12; 95% CI: 1.16-3.87).

CONCLUSION

In women with pregnancy-associated hypertension before initial discharge, non-Hispanic black women were at increased odds of postpartum readmission due to hypertension compared with non-Hispanic white women.

Predictors of readmission for postpartum preeclampsia

Objective: To develop a predictive model for re-admission for postpartum preeclampsia (PPEC).Methods: A case-control study; cases were patients re-admitted for PPEC; controls were not re-admitted. Mixed linear modelling was used to develop a predictive model on the training set, then validated on the validation set.Results: Two-hundred-sixty-nine patients were readmitted, and matched to 538 controls. A risk calculator was developed and yielded a sensitivity and specificity for readmission of 80.9% and 53.5%, respectively.Conclusion: A predictive model using age, race, discharge blood pressures, and preeclampsia was able to predict re-admission for PPEC with a high level of sensitivity.

Triage Decisions Involving Pregnancy-Capable Patients: Educational Deficits and Emergency Nurses' Perceptions of Risk

BACKGROUND

In areas where obstetric services are not available, emergency departments often become the default for unplanned obstetric care, yet emergency nurses are not universally trained in the identification and treatment of obstetric emergencies. The purpose of this study was to explore emergency nurses' perception of acuity in the triage of pregnant or postpartum patients presenting to the emergency department with high-risk complaints and to identify facilitators and challenges to the accurate identification and treatment of these patients.

METHOD

A mixed-methods study was conducted using chart review data (N = 12,766) and focus group data (N = 39) from five emergency departments in the eastern United States.

RESULTS

In 86.5% of cases, pregnancy status was not documented. Ninety-four percent of pregnant patients with a systolic blood pressure over 140 mmHg were under-triaged. The overall theme of the qualitative data was acuity blindness, with identified barriers to assessment that included educational needs and triage processes and workflow issues.

CONCLUSION

There are significant knowledge deficits in the care of patients presenting with high-risk conditions associated with pregnancy. [J Contin Educ Nurs. 2021;52(1):21-29.].

Implementation of a text-based postpartum blood pressure monitoring program at 3 different academic sites

BACKGROUND

Up to 30% of patients with hypertensive disorders of pregnancy continue to have elevated blood pressures after delivery, often necessitating medication titration or hospital evaluation in the weeks following hospital discharge. A previous randomized controlled trial demonstrated that remote blood pressure monitoring programs led to an increase in the number of blood pressure measurements obtained and increased compliance with clinical guidelines regarding the monitoring of patients for persistent or worsening postpartum hypertension.

OBJECTIVE

The aims of this study were to measure the program participant response rates during the first 10 days after hospital discharge, to assess the replicability and scalability of the program, and to evaluate patient satisfaction at 3 distinct sites.

STUDY DESIGN

We conducted a prospective observational cohort study across 3 US academic medical centers during which postpartum participants with hypertensive disorders of pregnancy were enrolled in a previously validated, remote, text message-based blood pressure monitoring program known as Heart Safe Motherhood. English-speaking patients with access to a text message-enabled cell phone and with a diagnosis of hypertensive disorders of pregnancy were candidates for enrollment in the study. Each study site planned to enroll approximately 66 participants in this pilot implementation phase. All the enrolled participants received a validated blood pressure cuff, education on proper use of the device, and were sent text messages as a reminder to check their blood pressures twice daily for 10 days after discharge. They were asked to reply via text message with their blood pressure readings. All blood pressure readings were reviewed via a web-based platform by a physician. Physicians communicated with patients whose blood pressure levels exceeded 160 mm Hg systolic or 100 mm Hg diastolic to determine the next management steps. Enrollees were texted a survey at the end of the 10 days and the responses were recorded. The proportion of eligible parturients who were enrolled, the number of measured blood pressure values, and the postprogram survey results were measured. We assessed the number of patients who reported elevated blood pressures, required antihypertensive medication, and were readmitted for blood pressure control during the program duration.

RESULTS

A total of 199 participants were enrolled in the program: 66 at site A, 67 at site B, and 66 at site C. In the 10 days after hospital discharge, 192 (97%) participants submitted at least 1 blood pressure measurement via text message. More enrolled patients submitted a blood pressure measurement on postpartum days 7 to 10 (171, 86%) than on days 1 to 4 (134, 67%). A total of 126 (63%) participants submitted blood pressures during both time frames. Elevated blood pressures were recorded for 70 (35%) participants, 32 (16%) of whom were started on oral antihypertensives after discussing their blood pressure measurements with an on-call provider. A total of 10 participants (5%) required hypertension-related readmission after delivery. The end-of-program survey was completed by 98 (49%) of the participants. Of those who completed the survey, 93% agreed that the program helped them to monitor their blood pressure (89% at site A; 88% at site B, and 100% at site C), and 93% would recommend it to friends or family members (94% at site A, 96% at site, and 88% at site C).

CONCLUSION

Postpartum participants are willing and capable of using the Heart Safe Motherhood program for remote blood pressure monitoring and reported high satisfaction with the program across multiple sites. Our study demonstrated that this remote blood pressure monitoring program can be implemented successfully and demonstrated replicable efficacy at diverse sites.

Posterior Reversible Encephalopathy Syndrome Is the Common Cause of New-Onset Seizures in the Peripartum Period: A Tertiary Hospital-Based Study in South India

Background and Purpose

To study the aetiolgic spectrum of new-onset seizures in the peripartum period in south India.

Methods

This is a retrospective analysis of case records of women with new-onset seizures in the peripartum period admitted between 2005 and 2018 (13 years).

Results

Of the 41 women (mean age, 26.20 years; range, 19–35 years) admitted, 20 patients (48.7%) had hypertensive disorders of pregnancy (HDP). Generalized tonic-clonic seizure (88%) was the common seizure type. The aetiologies of new-onset seizures were: 1) pregnancy-related aetiologies in 33 (80.5%) and 2) non-pregnancy-related aetiologies in eight (19.5%). Of the pregnancy-related aetiologies, posterior reversible encephalopathy syndrome (PRES) was the commonest cause in 24 patients (58.5%). Seizure cluster presentation was common in patients with PRES (p=0.0087). Of the eight women with non-pregnancy-related aetiologies, endemic central nervous system (CNS) infections accounted for three (7.3%; brain tuberculoma in one and neurocystocercosis in two) of the aetiology. All the women had Glasgow outcome scale-5 outcome.

Conclusions

PRES was the common cause of new-onset seizures in peripartum period in this cohort. Endemic infections of CNS accounted for 7.3% of the total aetiological spectrum. This study suggests that the possibility of PRES should be considerd in woman with HDP and seizure cluster in peripartum period.

Hypertension in Women Across the Lifespan

PURPOSE OF REVIEW

We will highlight the biological processes across a women's lifespan from young adulthood through menopause and beyond that impact blood pressure and summarize women's representation in hypertension clinical trials.

RECENT FINDINGS

Throughout their lifetime, women potentially undergo several unique sex-specific changes that may impact their risk of developing hypertension. Blood pressure diagnostic criteria for pregnant women remains 140/90 mmHg and has not been updated for concordance with the 2017 ACC/AHA guideline due to a lack of data. Although on a population level, women develop hypertension at later ages than men, new data shows women's BP starts to increase as early as the third decade. Understanding how age and sex both contribute to hypertension in elderly women is crucial to identify optimal blood pressure and treatment targets. Effective screening, monitoring, and treatment of hypertension throughout a women's lifespan are necessary to reduce CVD risk. We highlight several gaps in the literature pertaining to understanding sex-specific hypertension mechanisms.

Factors associated with postpartum readmission for hypertensive disorders of pregnancy

BACKGROUND

Postpartum readmission has negative implications for patients and health systems. Previous studies suggest that up to 5% of women with hypertensive disorders of pregnancy experience postpartum readmission. Studies examining factors associated with postpartum readmission for hypertension have had small sample sizes and conflicting results.

OBJECTIVE

This study aimed to characterize the incidence of and risk factors for postpartum readmission for hypertensive disorders of pregnancy among a cohort of women with preexisting hypertensive disorders of pregnancy.

STUDY DESIGN

This was a retrospective cohort study of pregnant women with known hypertensive disorders of pregnancy who delivered live births in a large managed care organization in 2018. The primary outcome was hospital readmission for a hypertensive diagnosis or stroke within 42 days after delivery. The primary exposure of interest was persistent postpartum hypertension, defined as a maximum systolic blood pressure of ≥140 mm Hg or maximum diastolic blood pressure of ≥90 mm Hg within 24 hours before discharge from delivery hospitalization. Continuous and categorical variables were compared using bivariate analysis. Risk factors independently associated with postpartum readmission were identified using multivariable logistic regression.

RESULTS

Of 42,022 women who delivered in 2018, 7151 had hypertensive disorders of pregnancy-an incidence of 17%. The rate of postpartum readmission among women with hypertensive disorders of pregnancy was 4.43% (317 of 7151). The following risk factors were associated with increased odds of postpartum readmission in women with hypertensive disorders of pregnancy: systolic blood pressure of ≥140 mm Hg within 24 hours before discharge (adjusted odds ratio, 2.29; 95% confidence interval, 1.71-3.07), diastolic blood pressure of ≥90 mm Hg within 24 hours before discharge (adjusted odds ratio, 1.33; 95% confidence interval, 1.02-1.73), maternal age of ≥30 years (30-34: adjusted odds ratio, 1.57; 95% confidence interval, 1.12-2.19; 35-39: adjusted odds ratio, 2.36; 95% confidence interval, 1.70-3.28; ≥40: adjusted odds ratio, 2.95; 95% confidence interval, 1.95-4.46), receipt of magnesium sulfate (adjusted odds ratio, 1.47; 95% confidence interval, 1.11-1.94), and receipt of inpatient rapid-acting antihypertensive medication (adjusted odds ratio, 1.46; 95% confidence interval, 1.10-1.93). In addition, 1 blood pressure of ≥140/90 mm Hg within 24 hours before discharge increased the odds of readmission (adjusted odds ratio, 1.98; 95% confidence interval, 1.37-2.87). Furthermore, 2 or more elevated blood pressure values further increased the odds (adjusted odds ratio, 3.14; 95% confidence interval, 2.33-4.24). Median postpartum day of readmission was day 5 (interquartile range=3).

CONCLUSION

Hospital readmission for postpartum hypertension was associated with persistent postpartum hypertension (blood pressure of ≥140/90 mm Hg), increasing maternal age, and more severe antepartum hypertension. Women with these characteristics may be targeted in future quality initiatives to mitigate readmission.

Management of Women With Acquired Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 3/5

Acquired cardiovascular conditions are a leading cause of maternal morbidity and mortality. A growing number of pregnant women have acquired and heritable cardiovascular conditions and cardiovascular risk factors. As the average age of childbearing women increases, the prevalence of acute coronary syndromes, cardiomyopathy, and other cardiovascular complications in pregnancy are also expected to increase. This document, the third of a 5-part series, aims to provide practical guidance on the management of such conditions encompassing pre-conception through acute management and considerations for delivery.

Feasibility of Using Blood Pressure Self-Monitoring and the Epic MyChart Blood Pressure Flowsheet to Monitor Blood Pressure After Preeclampsia

Preeclampsia is associated with significant morbidity and mortality. Women who experienced preeclampsia require close blood pressure surveillance postpartum. Remote monitoring of blood pressure using a mobile health application may be a viable method of surveillance in this population. The purpose of this project was to assess the feasibility of using the MyWellSpan mobile application to engage postpartum women who experienced preeclampsia in blood pressure self-monitoring. Women who chose to participate were provided an automatic blood pressure cuff and educational materials and were enrolled in MyWellSpan. A survey created by the authors asked participants to rate by Likert scale their satisfaction with the program and ease of use of the blood pressure cuff and self-monitoring. The electronic health record was reviewed retrospectively to assess utilization of the MyWellSpan mobile application to document blood pressure. The majority of women who participated reported that operating the blood pressure cuff was very easy and felt that it would be very easy to monitor their blood pressure twice daily. Sixty-nine percent of those women in the program electronically submitted at least 1 blood pressure measurement, thus confirming the feasibility of self-monitoring and reporting using a mobile application.

[Pharmacological treatment of non-severe hypertension during pregnancy, postpartum and breastfeeding]

Hypertension (HTN) in pregnancy is defined as systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90 mmHg. Based on the values, it is classified as non-severe (< 160/110 mmHg) and severe (≥ 160/110 mmHg). Before starting treatment in non-severe HTN, white- coat HTN should be ruled out. If outpatient management is possible, pharmacological initiation is suggested with sustained high values, avoiding < 120/80 mmHg. Safe drugs during pregnancy are methyldopa, labetalol, and nifedipine-retard. The use of nifedipine-XL or amlodipine can be considered with a lower level of evidence of safety. Diuretics, atenolol, and other beta-blockers for antihypertensive purposes is not recommended in this period. Renin-angiotensin-aldosterone system inhibitors are strictly contraindicated. In postpartum and breastfeeding, the same therapeutic regimen used during pregnancy can be maintained, trying early withdrawal of methyldopa. During puerperium, amlodipine and enalapril are safe, with minimal excretion in breast milk.

Furosemide for Accelerated Recovery of Blood Pressure Postpartum in women with a hypertensive disorder of pregnancy: A Randomized Controlled Trial

[Figure: see text].

Risk factors for postpartum readmission for preeclampsia or hypertension before delivery discharge among low-risk women: a case-control study

BACKGROUND

Postpartum hypertension or preeclampsia is one of the most frequent reasons for readmission after delivery discharge, and risk factors for readmission remain poorly characterized.

OBJECTIVE

This study aimed to determine risk factors of postpartum readmission for hypertension or preeclampsia among low-risk women before delivery discharge.

STUDY DESIGN

We conducted a nested case-control study from 2012 to 2015 at a tertiary care medical center. Cases were identified using diagnostic codes for postpartum transient hypertension, mild preeclampsia, severe preeclampsia, eclampsia, superimposed preeclampsia, and unspecified hypertension and readmission within 6 weeks of delivery. Controls not readmitted for hypertension or preeclampsia were time matched within 4 weeks of the delivery date to each case. We fit multivariable logistic regression models to identify independent risk factors for postpartum readmission for hypertension or preeclampsia and then calculated a receiver operating characteristic curve of the final model to assess model discrimination.

RESULTS

Within the source cohort resulting in 58 cases and 232 matched controls, the rate of postpartum readmission for preeclampsia or hypertension was 0.4% (n=58 of 14,503). The median time to readmission was 6 days (range, 2-15 days), and 40% of cases had an outpatient postpartum visit before readmission. In multivariable analysis, non-Hispanic black race (adjusted odds ratio, 2.14; 95% confidence interval, 0.99-4.59), gestational hypertension (adjusted odds ratio, 2.70; 95% confidence interval, 1.12-6.54), preeclampsia during delivery admission (adjusted odds ratio, 3.12; 95% confidence interval, 1.29-7.50), and maximum postpartum systolic blood pressure during delivery admission (adjusted odds ratio, 1.05; 95% confidence interval, 1.03-1.08) were risk factors for readmission. This model had a good discriminative ability to predict women who would require readmission for preeclampsia or hypertension (area under the curve, 0.83; 95% confidence interval, 0.74-0.89). Using these 4 factors to illustrate this model, the predicted risk of readmission ranged from <1% in the lowest risk scenario (eg, postpartum systolic blood pressure of 120 mm Hg + no hypertensive disorders of pregnancy + white race) to 26% in the highest risk scenario (eg, postpartum systolic blood pressure of 160 mm Hg + preeclampsia + black race).

CONCLUSION

Risk factors of postpartum readmission for hypertension or preeclampsia can be identified at the time of delivery discharge among low-risk women, regardless of an antenatal hypertensive disorder. A next step could be using these risk factors to develop a predictive model to guide postpartum care.

Evaluation of different blood pressure assessment strategies and cutoff values to predict postpartum hypertension-related readmissions: a retrospective cohort study

BACKGROUND

The American College of Obstetricians and Gynecologists suggests the initiation of postpartum antihypertensive treatment for women with hypertension in the postpartum period, a systolic blood pressure of ≥150 mm Hg or diastolic blood pressure of ≥100 mm Hg on 2 occasions at least 4 to 6 hours apart; however, the utility and validity of this strategy for preventing postpartum hypertension-related readmission remain unknown.

OBJECTIVE

The primary objective was to evaluate the accuracy of different blood pressure assessment strategies for predicting postpartum hypertension-related readmissions. The secondary objective was to consider the impact of using different blood pressure thresholds for initiating postpartum antihypertensive treatment vs the impact of using the current blood pressure threshold recommended by the American College of Obstetricians and Gynecologists.

STUDY DESIGN

A retrospective cohort study of 24,917 women who delivered at a single midwestern academic hospital between January 1, 2009, and June 30, 2015. Of those women, 3830 were identified as hypertensive, and 112 of 3830 women (2.92%) were readmitted for hypertension management. Blood pressures measured between delivery and 72 hours after delivery were used to evaluate 3 different blood pressure assessment strategies: average systolic or diastolic blood pressure exceeding the predetermined threshold (strategy 1), maximum systolic or diastolic blood pressure exceeding the predetermined threshold on 1 occasion (strategy 2), and maximum systolic or diastolic blood pressure exceeding the predetermined threshold on 2 occasions at least 4 hours apart (strategy 3). Analyzed blood pressure thresholds included all the integer blood pressure values between 100/50 mm Hg to 160/110 mm Hg for strategy 1 and 120/70 mm Hg to 190/140 mm Hg for strategies 2 and 3. The primary outcome was hypertension-related postpartum readmission. Receiver operating characteristic curves and the area under the curve were used to measure the predictive value of these strategies.

RESULTS

The American College of Obstetricians and Gynecologists' recommendation of using blood pressure ≥150/100 mm Hg as a threshold had a sensitivity of 38% and specificity of 95%, whereas following strategy 3 and reducing the threshold to 140/90 mm Hg demonstrated a sensitivity of 71% and specificity of 84%. The area under the curve for the 3 strategies were as follows: strategy 1 (area under the curve, 0.81; 95% confidence interval, 76.95-85.08), strategy 2 (area under the curve, 0.79; 95% confidence interval, 74.70-82.81), and strategy 3 (area under the curve, 0.83; 95% confidence interval, 79.83-87.24). The difference between the areas under the curve of strategies 2 and 3 was statistically significant (P<.0001).

CONCLUSION

The strategy of using the maximum systolic or diastolic blood pressure exceeding the blood pressure threshold on 2 occasions at least 4 hours apart at lower blood pressure thresholds can predict readmissions with higher sensitivity or specificity. Compared with the threshold of the American College of Obstetricians and Gynecologists' recommended blood pressure of ≥150/100 mm Hg, if the threshold for the postpartum antihypertensive treatment initiation was lowered to a blood pressure of ≥140/90 mm Hg, it would significantly reduce postpartum readmissions.

Risk factors for re-presentation for postpartum hypertension in patients without a history of hypertension or preeclampsia

BACKGROUND

Re-presentation for evaluation of hypertension following discharge after delivery is common. However, a subset of patients who re-present for evaluation of postpartum hypertension do not have a history of hypertension. Identification of those at risk may help guide postpartum management and prevent re-presentations to the hospital.

OBJECTIVE

This study aimed to establish risk factors for re-presentation for hypertension within 30 days of discharge after delivery in patients without a history of hypertension compared with women who did not re-present and to distinguish from risk factors for re-presentation for another reason.

STUDY DESIGN

Subjects were identified through data extraction from a single institution between January 2012 and December 2018. We included subjects without an International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision code for (1) chronic hypertension or (2) a hypertensive disorder of pregnancy during their delivery encounter who re-presented to the hospital within 30 days. Thus, the re-presentation group was divided into the following 2 groups: those who re-presented for hypertension and those who re-presented for any other reason. Each re-presentation group was compared with the cohort of patients who delivered within the study window and did not re-present using the Student t test or Wilcoxon tests for continuous variables and chi-square or Fisher's exact tests for categorical variables. Multivariable regression was also performed on all potentially important risk factors.

RESULTS

Factors that emerged as uniquely significant in the re-presentation group for hypertension were maternal age of ≥40 years and antenatal prescription of low-dose aspirin. Black race and body mass index of ≥30 kg/m², although significant in both re-presentation groups, were more strongly predictive of re-presentation for hypertension. These factors remained independently significant when compared with each other in a multivariable analysis.

CONCLUSION

There are identifiable risk factors for postpartum re-presentation for hypertension in patients without a history of hypertension. Upon discharge, providers may consider close blood pressure monitoring and follow-up in patients who have any of the following risk factors: age of ≥40 years, black race, body mass index of ≥30 kg/m², or those who were prescribed low-dose aspirin in pregnancy.

Preeclampsia: Linking Placental Ischemia with Maternal Endothelial and Vascular Dysfunction

Preeclampsia (PE), a hypertensive disorder, occurs in 3% to 8% of pregnancies in the United States and affects over 200,000 women and newborns per year. The United States has seen a 25% increase in the incidence of PE, largely owing to increases in risk factors, including obesity and cardiovascular disease. Although the etiology of PE is not clear, it is believed that impaired spiral artery remodeling of the placenta reduces perfusion, leading to placental ischemia. Subsequently, the ischemic placenta releases antiangiogenic and pro-inflammatory factors, such as cytokines, reactive oxygen species, and the angiotensin II type 1 receptor autoantibody (AT1-AA), among others, into the maternal circulation. These factors cause widespread endothelial activation, upregulation of the endothelin system, and vasoconstriction. In turn, these changes affect the function of multiple organ systems including the kidneys, brain, liver, and heart. Despite extensive research into the pathophysiology of PE, the only treatment option remains early delivery of the baby and importantly, the placenta. While premature delivery is effective in ameliorating immediate risk to the mother, mounting evidence suggests that PE increases risk of cardiovascular disease later in life for both mother and baby. Notably, these women are at increased risk of hypertension, heart disease, and stroke, while offspring are at risk of obesity, hypertension, and neurological disease, among other complications, later in life. This article aims to discuss the current understanding of the diagnosis and pathophysiology of PE, as well as associated organ damage, maternal and fetal outcomes, and potential therapeutic avenues. © 2021 American Physiological Society. Compr Physiol 11:1315-1349, 2021.

Hypertensive Disorders of Pregnancy

Hypertension is the most common medical disorder occurring during pregnancy and a leading cause of maternal and perinatal morbidity and mortality. Accurate blood pressure measurement and the diagnosis and treatment of hypertensive disorders during pregnancy and in the postpartum period are pivotal to improve outcomes. This article details hemodynamic adaptations to pregnancy and provides an approach to the prevention, diagnosis, and management of hypertensive disorders of pregnancy (HDP) and hypertensive emergencies. In addition, it reviews optimal strategies for the care of women with hypertension during the fourth trimester and beyond to minimize future cardiovascular risk.

Pharmaco-vigilance of oral MethylErgometrine prescriptions for delayed and secondary postpartum haemorrhage

Objectives The objectives of this study were to quantify the prescription of oral methergin tablets in a busy Women's Hospital, assess the stated indications for such prescription and highlight the issues and safety profile of Methergin use especially in the postpartum patient. Methods Review of prescription data for oral Methergin and the corresponding annual figures on primary and secondary postpartum hemorrhage. Results Over a period of 5 years, oral Methergin prescriptions for delayed and secondary postpartum hemorrhage constituted less than 1% of the overall prescription in Obstetrics and Gynaecology, which ranged between 1214 and 2085 per year. The numbers were too few to ascertain any relationship with both types of postpartum hemorrhage. Although stated on the relevant Patient Information leaflet, no local or regional guideline on its use exist. Conclusions Specific and random trend monitoring of medications for continuing safety profile, risk benefit issues, or unapproved indication, may help in identifying, preventing and mitigating any medication safety matters. Clinical pharmacists in collaboration with physicians are well placed in conducting such pharmacovigilance activities to improve medication safety.

Placental Findings in Postpartum Preeclampsia: A Comparative Retrospective Study

OBJECTIVE

Preeclampsia is a multifactorial placental disease that can occur after delivery. The pathophysiology of postpartum preeclampsia remains unknown. The objective was to describe placental findings in postpartum preeclampsia.

STUDY DESIGN

This is a case-control study, comparing the placental histologic findings in four groups of 30 patients with postpartum preeclampsia, early-onset preeclampsia, late-onset preeclampsia, and normotensive controls.

RESULTS

Placentas of postpartum preeclampsia had a mean placental weight not different from that of late-onset preeclampsia at a similar gestational age (479.0 ± 152.7 vs. 521.3 ± 144.1 g, p = 0.07); they showed a higher rate of acute deciduitis of 42.4% than early preeclampsia (5.7%, p < 0.01) or in controls (3.2%, p < 0.01); 18.2% had decidual arteriolopathy, with no significant difference with other groups. These placentas had fewer villous infarcts as compared with early preeclampsia (9.1 vs. 62.9%, p < 0.01) and less accelerated maturation of villi (24.2 vs. 74.3%, p < 0.01).

CONCLUSION

There were no significant differences for decidual arteriolopathy and villous infarcts among postpartum preeclampsia, late-onset preeclampsia, and the controls. This suggests that postpartum preeclampsia is more of a maternal disease in which the placenta may act as a priming effect in predisposed mothers and becomes clinically apparent after delivery.

Successful implementation of text-based blood pressure monitoring for postpartum hypertension

OBJECTIVES

A clinical trial showed postpartum text-based blood pressure (BP) monitoring is effective in meeting clinical guidelines and reduces racial disparities in postpartum hypertension care. Our objective was to compare clinical outcomes to those from a clinical trial after implementation of the program in a second hospital within our hospital system.

STUDY DESIGN

Comparison of women randomized to text-based BP monitoring in a clinical trial compared to an implementation cohort clinically enrolled in text-based BP monitoring. BP outcomes and postpartum visit were compared in bivariate and multivariable analyses.

MAIN OUTCOME MEASURES

BP ascertainment was defined as at least 1 BP texted during the 10 days of monitoring. American College of Obstetricians and Gynecologists (ACOG) recommendation was defined as BP sent on postpartum day 3-4 and again day 7-10.

RESULTS

The implementation cohort had 333 women compared to 103 in the trial cohort. The implementation cohort was older (p < 0.001), and more likely to be non-Black race (p < 0.001), married (<0.001), and have commercial insurance (<0.001). BP ascertainment (95.5% vs. 92.2%, adjusted OR 1.41, [95% CI 0.55, 3.58]) and proportion meeting ACOG recommendations (84.7% vs. 81.6%, adjusted OR 0.89 [95% CI 0.48, 1.64]) were similar between groups. There were no differences in BP ascertainment among Black and non-Black women in the trial or implementation cohort.

CONCLUSIONS

Text-based BP monitoring performed similarly in an implementation cohort compared to the trial participants. This program is scalable to manage postpartum hypertension and reduce racial disparities in postpartum care in women with hypertensive disorders of pregnancy.

Postpartum Hypertension

PURPOSE OF REVIEW

Hypertension affects approximately 10% of pregnancies and may persist in the postpartum period. Furthermore, de novo hypertension may present after delivery, but its exact prevalence is not verified. Both types of hypertension expose the mother to eventually severe complications like eclampsia, stroke, pulmonary edema, and HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome.

RECENT FINDINGS

Until today, there are limited data regarding the risk factors, pathogenesis, and pathophysiology of postpartum hypertensive disorders. However, there is certain evidence that preeclampsia may in large part be responsible. Women who experienced preeclampsia during pregnancy, although considered cured after delivery and elimination of the placenta, continue to present endothelial and renal dysfunction in the postpartum period. The brain and kidneys are particularly sensitive to this pathological vascular condition, and severe complications may result from their involvement. Large randomized trials are needed to give us the evidence that will allow a timely diagnosis and treatment. Until then, medical providers should increase their knowledge regarding hypertension after delivery because many times there is an underestimation of the complications that can ensue after a misdiagnosed or undertreated postpartum hypertension.

Pre-eclampsia with severe features: management of antihypertensive therapy in the postpartum period

Introduction

there is variance in both the types and combinations of antihypertensive drugs used for managing pre-eclampsia in the postpartum period. Knowledge of the most common and suitable single or combination antihypertensive drug therapies in the postpartum period will minimize harmful effects, promote adherence to medications, overcome any fears that lactating mothers may have about these drugs and will assist in healthcare planning. Objective: to determine the types of antihypertensive drug therapies used in managing pre-eclampsia with severe features (sPE) in the postpartum period in a regional hospital in South Africa.

Methods

fifty consecutively presenting pregnant women with sPE were followed up prospectively from the pre-delivery period (within 48 hours before delivery) until day 3 postpartum. The antihypertensive drug therapies administered to the participants were observed. Their blood pressures were measured daily at 04: 00, 08: 00, 14: 00 and 22: 00 hours.

Results

nifedipine was the commonest rapid-acting agent used for severe hypertension. Prepartum, 9 different combinations of antihypertensive drugs were prescribed; alpha-methyldopa was the commonest single long-acting agent used. Postpartum, the number of different drug combinations administered were 15, 18, 22 and 16 on days 0, 1, 2 and 3 respectively. Alpha-methyldopa was the commonest single agent used on postpartum days 0 - 2 while hydrochlorothiazide was the most frequently used single agent on postpartum day 3. Postpartum, the commonest combination therapy was alpha-methyldopa and amlodipine on day 0; alpha-methyldopa and amlodipine as a regimen as well as alpha-methyldopa, amlodipine and hydrochlorothiazide as another regimen on day 1; alpha-methyldopa and amlodipine on day 2; and many amlodipine-based regimens on day 3.

Conclusion

a variety of antihypertensive drug combinations were used in the postpartum period indicating the need for standardised guidelines; however, detailed studies are required to evaluate their efficacies completely.

Efficacy of Diltiazem for the Control of Blood Pressure in Puerperal Patients with Severe Preeclampsia: A Randomized, Single-Blind, Controlled Trial

BACKGROUND

Postpartum preeclampsia is a serious disease related to high blood pressure that occurs commonly within the first six days after delivery.

OBJECTIVE

To evaluate if diltiazem improves blood pressure parameters in early puerperium patients with severe preeclampsia. Methodology. A randomized, single-blind longitudinal clinical trial of 42 puerperal patients with severe preeclampsia was carried out. Patients were randomized into two groups: the experimental group (n = 21) received diltiazem (60 mg) and the control group (n = 21) received nifedipine (10 mg). Both drugs were orally administered every 8 hours. Systolic, diastolic, and mean blood pressures as well as the heart rate were recorded and analyzed (two-way repeated measures ANOVA) at baseline and after 6, 12, 18, 24, 30, 36, 42, and 48 hours. Primary outcome measures were all the aforementioned blood pressure parameters. Secondary outcome measures included the number of hypertension and hypotension episodes along with the length of stay in the intensive care unit.

RESULTS

No statistical differences were found between groups (diltiazem vs. nifedipine) regarding basal blood pressure parameters. Interarm differences in blood pressure (systolic, diastolic, and mean) and heart rate were statistically significant between treatment groups from 6 to 48 hours. Patients in the diltiazem group had lower blood pressure levels than patients in the nifedipine group. Significantly, patients who received diltiazem had fewer hypertension and hypotension episodes and stayed fewer days in the intensive care unit than those treated with nifedipine.

CONCLUSIONS

Diltiazem controlled arterial hypertension in a more effective and uniform manner in patients under study than nifedipine. Patients treated with diltiazem had fewer collateral effects and spent less time in the hospital. This trial is registered with NCT04222855.

Influence of maternal and perinatal characteristics on risk of postpartum chronic hypertension after pre-eclampsia

OBJECTIVE

To assess the prevalence of new-onset postpartum chronic hypertension (PPCH) after pre-eclampsia and to determine the factors are associated with it.

METHODS

This study was conducted in a tertiary center in south India, between June 2018 and February 2019, consisting of pre-eclamptic women who were recruited as part of an ongoing cohort and had completed at least 3 months of postpartum follow-up. Demographic, medical, and laboratory details were collected. Primary outcome was a diagnosis of new-onset PPCH at 3 months.

RESULTS

PPCH at 3 months was noted in 32 (18.1%) women. During postnatal follow-up, 2 (1.1%) women experienced hemiplegia from stroke and 19 (10.7%) had elevated serum creatinine levels (>1.1 mg/dL). On multivariate analysis, advancing maternal age (adjusted odds ratio [aOR] 1.10, 95% confidence interval [CI] 1.01-1.21), multiparity (aOR 2.79, 95% CI 1.07-7.24), and eclampsia (aOR 3.07, 95% CI 1.03-9.13) increased the risk of PPCH at 3 months postpartum.

CONCLUSION

One in five women present with a diagnosis of new-onset PPCH within 3 months postpartum in a cohort of predominantly preterm and/or severe pre-eclampsia. A significant but weak association of PPCH with peripartum clinical characteristics was noted. The role of biochemical, hemodynamic, and echocardiographic biomarkers should be evaluated for prediction of PPCH after pre-eclampsia in future studies.

Warren C. Clinical presentation and outcomes of pre-eclampsia and eclampsia at a national hospital, Kenya: A retrospective cohort study

BACKGROUND

Hypertensive disorders in pregnancy including pre-eclampsia are associated with maternal and newborn mortality and morbidity. Early detection is vital for effective treatment and management of pre-eclampsia. This study examines and compares the clinical presentation and outcomes between early- and late-onset pre-eclampsia over a two year period.

METHODS

A retrospective cohort study design which examines socio-demographic characteristics, treatment, outcomes, and fetal and maternal complications among women with early onset of pre-eclampsia (EO-PE) and late onset of pre-eclampsia (LO-PE). De-identified records of women who attended antenatal, intrapartum and postnatal care services and experienced pre-eclampsia at Kenyatta National teaching and referral hospital were reviewed. We used chi square, t-test, and calculated odds ratio to determine any significant differences between the EO-PE and LO-PE cohorts.

RESULTS

Out of 620 pre-eclamptic and eclamptic patients' records analyzed; 44 percent (n = 273) exhibited EO-PE, while 56 percent had late onset. Women with EO-PE compared to LO-PE had greater odds of adverse maternal and perinatal outcomes including hemolysis elevated liver enzymes and low platelets (HELLP) syndrome (OR: 4.3; CI 2.0-10.2; p<0.001), renal dysfunction (OR; 1.7; CI 0.7-4.1; p = 0.192), stillbirth (OR = 4.9; CI 3.1-8.1; p<0.001), and neonatal death (OR: 8.5; CI 3.8-21.3; p<0.001). EO-PE was also associated with higher odds of prolonged maternal hospitalization, beyond seven days (OR = 5.8; CI 3.9-8.4; p<0.001), and antepartum hemorrhage (OR = 5.8; CI 1.1-56.4; p<0.001). Neonates born after early onset of pre-eclampsia had increased odds of respiratory distress (OR = 17.0; CI 9.0-32.3, p<0.001) and birth asphyxia (OR: 1.9; CI 0.7-4.8; p = 0.142).

CONCLUSIONS

The profiles and outcomes of women with EO-PE (compared to late onset) suggest that seriousness of morbidity increases with earlier onset. To reduce adverse neonatal and maternal outcomes, it is critical to identify, manage, referral and closely follow-up pregnant women with pre-eclampsia throughout the pregnancy continuum.

ETHICAL APPROVAL

This study protocol was approved by Population Council's research ethics Institutional Review Board, Protocol 813, and KNH-UoN Ethics and Research Committee, Protocol 293/06/2017.

Exploring the Use of Telemonitoring for Patients at High Risk for Hypertensive Disorders of Pregnancy in the Antepartum and Postpartum Periods: Scoping Review

Background

High blood pressure complicates 2% to 8% of pregnancies, and its complications are present in the antepartum and postpartum periods. Blood pressure during and after pregnancy is routinely monitored during clinic visits. Some guidelines recommend using home blood pressure measurements for the management and treatment of hypertension, with increased frequency of monitoring for high-risk pregnancies. Blood pressure self-monitoring may have a role in identifying those in this high-risk group. Therefore, this high-risk pregnancy group may be well suited for telemonitoring interventions.

Objective

The aim of this study was to explore the use of telemonitoring in patients at high risk for hypertensive disorders of pregnancy (HDP) during the antepartum and postpartum periods. This paper aims to answer the following question: What is the current knowledge base related to the use of telemonitoring interventions for the management of patients at high risk for HDP?

Methods

A literature review following the methodological framework described by Arksey et al and Levac et al was conducted to analyze studies describing the telemonitoring of patients at high risk for HDP. A qualitative study, observational studies, and randomized controlled trials were included in this scoping review.

Results

Of the 3904 articles initially identified, 20 met the inclusion criteria. Most of the studies (13/20, 65%) were published between 2017 and 2018. In total, there were 16 unique interventions described in the 20 articles, all of which provide clinical decision support and 12 of which are also used to facilitate the self-management of HDP. Each intervention’s design and process of implementation varied. Overall, telemonitoring interventions for the management of HDP were found to be feasible and convenient, and they were used to facilitate access to health services. Two unique studies reported significant findings for the telemonitoring group, namely, spontaneous deliveries were more likely, and one study, reported in two papers, described inductions as being less likely to occur compared with the control group. However, the small study sample sizes, nonrandomized groups, and short study durations limit the findings from the included articles.

Conclusions

Although current evidence suggests that telemonitoring could provide benefits for managing patients at high risk for HDP, more research is needed to prove its safety and effectiveness. This review proposes four recommendations for future research: (1) the implementation of large prospective studies to establish the safety and effectiveness of telemonitoring interventions; (2) additional research to determine the context-specific requirements and patient suitability to enhance accessibility to healthcare services for remote regions and underserved populations; (3) the inclusion of privacy and security considerations for telemonitoring interventions to better comply with healthcare information regulations and guidelines; and (4) the implementation of studies to better understand the effective components of telemonitoring interventions.

Clinical Course, Associated Factors, and Blood Pressure Profile of Delayed-Onset Postpartum Preeclampsia

OBJECTIVE

To identify clinical risk factors associated with development of delayed-onset postpartum preeclampsia, and to characterize management and subsequent risk of cardiovascular disease.

METHODS

This is a case-control study of women admitted to the hospital with delayed-onset postpartum preeclampsia (defined as a new diagnosis of preeclampsia presenting between 48 hours and 6 weeks postpartum) compared with women with full-term, uncomplicated pregnancies without a hypertensive diagnosis or diabetes. Included women delivered between January 2014 and June 2018 at a single tertiary care center. Women with an antenatal diagnosis of preeclampsia or chronic hypertension were excluded. Univariate analysis was used to identify risk factors associated with delayed-onset postpartum preeclampsia and to compare rates of hypertension and antihypertensive medication use, with follow-up beyond 3 months postpartum among a subset of women in the control group who were matched 2:1 with women in the case group. Multivariable logistic regression was performed and included covariates identified in a backward stepwise approach.

RESULTS

Compared with women in the control group (n=26,936), women with delayed-onset postpartum preeclampsia (n=121) were significantly more likely to be of non-Hispanic black race (31.4% vs 18.0%), obese (39.7% vs 20.1%), and deliver by cesarean (40.5% vs 25.8%), all P<.01. For women diagnosed with delayed-onset postpartum preeclampsia, the median postpartum day of presentation was 7.0 (interquartile range 5.0-9.0), with 93.4% presenting secondary to symptoms, which was most commonly a headache. A majority (73.6%) underwent imaging studies, and 49.6% received intravenous antihypertensive agents. A total of 86 (71.0%) women with delayed-onset postpartum preeclampsia and 169 (72.8%) women in the control group had longer term information available, with a median follow-up time of 1.5 years (interquartile range 0.8-2.8). Delayed-onset postpartum preeclampsia was associated with higher blood pressures at 3 months postpartum or later (median systolic 130 mm Hg vs 112 mm Hg and median diastolic 80 mm Hg vs 70 mm Hg, P<.001).

CONCLUSION

Delayed-onset postpartum preeclampsia is associated with variable management strategies. There is substantial overlap between the clinical risk factors for delayed-onset postpartum preeclampsia and antepartum preeclampsia. Our findings suggest that delayed-onset postpartum preeclampsia is also associated with an increased risk of progression to chronic hypertension.

Comparison of process outcomes, clinical symptoms and laboratory values between patients with antepartum preeclampsia, antepartum with persistent postpartum preeclampsia, and new onset postpartum preeclampsia

OBJECTIVE

There is limited literature on postpartum preeclampsia for process outcomes, clinical symptoms, and laboratory values.

METHOD

Retrospective study comparing 3 groups of antepartum preeclampsia without postpartum preeclampsia (APNP; n = 43), antepartum preeclampsia with persistent postpartum preeclampsia (APYP; n = 59), and new onset postpartum preeclampsia (NEWYP; n = 18).

RESULTS

For process outcomes, NEWYP had higher odds for readmission as compared to APYP [OR: 5.41, 95 % CI: 1.34, 21.56, p = 0.02]. For clinical symptoms of postpartum highest systolic blood pressure NEWYP had greater values as compared to both APYP [B = 19.95, SE = 3.84, p < 0.001] and APNP [B = 23.63, SE = 2.87, p < 0.001]. For laboratory values of serum creatinine, NEWYP had greater values as compared to both APYP [B = 0.15, SE = 0.05, p = 0.01] and APNP [B = 0.17, SE = 0.05, p = 0.002].

CONCLUSION

NEWYP may represent a different disorder from APNP and APYP. We recommend close monitoring of NEWYP by clinicians.

Sleep Disordered Breathing, a Novel, Modifiable Risk Factor for Hypertensive Disorders of Pregnancy

PURPOSE OF REVIEW

Pathophysiology of hypertensive disorders of pregnancy (HDP), especially preeclampsia, has not been fully elucidated. Most trials aimed at the prevention of preeclampsia have failed to show significant benefit and investigation of novel, modifiable risk factors is sorely needed. Sleep disordered breathing (SDB), a group of disorders for which treatments are available, meets these criteria. SDB impacts about a third of all pregnancies and is associated with hypertension in the general non-pregnant population.

RECENT FINDINGS

Recent studies have shown a high prevalence of SDB, especially in complicated pregnancies. Several studies have shown that pregnant women with SDB have a higher risk for developing HDP, and these two disorders are associated with similar maternal long-term cardiovascular outcomes. Based on limited animal models of gestational intermittent hypoxia and human studies, SDB and HDP share similar risk factors and some pathophysiological mechanisms. However, there is paucity of studies addressing causality of this association and identifying therapeutic targets for intervention. Maternal SDB represents a novel and modifiable risk factor of HDP. Further studies are needed in order to establish the exact mechanisms underlying this association and to identify specific areas for clinical interventions.

Using mHealth in postpartum women with pre-eclampsia: Lessons learned from a qualitative study

OBJECTIVE

To explore perceptions and attitudes of postpartum women with pre-eclampsia towards remote monitoring (mHealth) and communication with the call center.

METHODS

A non-randomized cohort study was conducted in postpartum hypertensive women, recruited from a tertiary hospital between October 2015 and February 2016. Participants were categorized into users (using mHealth) and non-users (not using mHealth) to monitor vital signs at home over a 2-week period after discharge. Non-users were informed about functionality of mHealth. Both groups participated in a 30-minute phone interview at the end of the study. Directed content analysis of interview transcripts was conducted.

RESULTS

In total, 21 users and 16 non-users participated in the interview. Both groups perceived that mHealth helped manage their condition. However, non-users were concerned about the challenge of incorporating mHealth into their routine, whereas users mentioned that they liked using mHealth on a daily basis. They also stated that communication with nurses in the call center was helpful. Barriers identified by users included size of the blood pressure cuffs, size of the equipment set, wireless connection, and stress associated with mHealth monitoring. Users stated that they would have preferred using mHealth during pregnancy.

CONCLUSION

The findings provide useful insights to inform a successful remote monitoring program among perinatal and postpartum women.

Postpartum blood pressure trends are impacted by race and BMI

OBJECTIVE

Our objective was to evaluate postpartum blood pressure trends, and time to resolution of hypertension among women with hypertensive disorders of pregnancy, specifically focusing on impact of race and BMI on these trends.

METHODS

We performed a secondary analysis of a randomized trial that utilized a text-message based home blood pressure monitoring system. BPs for this study included both inpatient postpartum BPs as well as home BPs obtained from the text-based program. Women were followed from 12 h of delivery to 16 days postpartum. Outcomes were: (1) postpartum BP trend summaries from a linear mixed-effects regression model and (2) time to resolution of hypertension (defined as ≥ 48 h of BPs < 140/90) depicted using Kaplan Meier survival curves with hazard ratio estimates of association using Cox models.

RESULTS

Eighty-four women were included, of which 63% were black. Non-black women with a BMI < 35 kg/m² had steady decreases in systolic BP whereas other groups peaked around 6.5 days postpartum. BPs for women in the BMI < 35 group, regardless of race, remained in the normotensive range. Conversely, women with a BMI ≥ 35 had a systolic BP peak into the hypertensive range prior to declining. Diastolic BP peaked at an average of 8.5 days postpartum. Time to resolution of BPs differed by race and BMI groups (p = 0.012). Non-black women with a BMI < 35 had the shortest time to resolution and 81% of these women had resolution of hypertension. Only 49% of black women with a BMI < 35 had resolution of hypertension and approximately 40% of both black and non-black women with BMI ≥ 35 had resolution of hypertension.

CONCLUSION

We identified race and BMI to be determinants of postpartum BP trends and hypertension resolution. Further study is needed to determine if race and BMI targeted postpartum hypertension interventions may lead to faster blood pressure recovery and lower maternal morbidity postpartum.

ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease

Maternal heart disease has emerged as a major threat to safe motherhood and women's long-term cardiovascular health. In the United States, disease and dysfunction of the heart and vascular system as "cardiovascular disease" is now the leading cause of death in pregnant women and women in the postpartum period () accounting for 4.23 deaths per 100,000 live births, a rate almost twice that of the United Kingdom (). The most recent data indicate that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths (). Of further concern are the disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.

Preeclampsia, eclampsia, and posterior reversible encephalopathy syndrome

Preeclampsia is a disorder of pregnancy associated with gestational hypertension and end-organ dysfunction. Patients with eclampsia, by definition, have seizures as part of the clinical syndrome. However, patients with preeclampsia can also have other neurologic symptoms and deficits. Both disorders can be associated with radiographic abnormalities similar to that of posterior reversible encephalopathy syndrome, suggesting a common pathophysiology or unified clinical spectrum of disorders. This chapter reviews the pathophysiology, clinical presentation, diagnostic findings, and prognosis of patients with neurologic complications associated with preeclampsia and eclampsia.

Postpartum hypertensive disorders in the Emergency Department - A retrospective review of local practice in Calgary, Alberta

Hypertensive disorders of pregnancy (HDP) commonly occur postpartum and are associated with preventable maternal morbidity and mortality. HDP is the most common reason for presentation to the Emergency Department (ED) after delivery. However, given the broad range of non-specific symptoms, recognition and management of postpartum HDP may be delayed leading to serious adverse clinical outcomes.

OBJECTIVES

To describe: (1) the clinical presentation; (2) ED physician's diagnosis; and (3) current ED management of women with HDP in Calgary ED's.

METHODS

A retrospective review of postpartum women (within 42 days of delivery) attending three Calgary EDs between 2011 and 2012 was performed. Administrative data was used to randomly select 119 women; 44 with diagnostic codes for any HDP (labeled "HDP") and 75 with diagnostic codes for related diagnoses (e.g., abdominal pain, headache) (labeled "non-HDP"). Charts were reviewed for: maternal demographics; obstetrical history; and ED clinical findings, investigations and management.

RESULTS

Maternal characteristics were similar between groups. There was considerable overlap in clinical presentation between groups, with no significant difference for any presenting symptom. Only 52.3% (CI 40.0-64.3%) of women in the "HDP" group had HDP investigations (bloodwork and urinalysis) vs. 30.4% (CI 18.7-58.5%) of "non-HDP" (p = 0.072). HDP was diagnosed by the ED team in 42.9% (CI 31.1-55.5%) of the HDP group of whom only 40.3% (CI 28.7-53.1) received antihypertensive therapy.

CONCLUSIONS

Postpartum HDP is commonly under-recognized and under-treated in the ED, highlighting opportunities for interventions to improve the recognition and management of postpartum HDP.

Primary hyperaldosteronism presenting as persistent postpartum hypertension: Illustrative case and systematic review

We present a case of persistent postpartum hypertension found to be secondary to primary hyperaldosteronism in a woman with a history of recurrent hypertensive disorders of pregnancy and associated fetal complications. Our systematic review revealed only 18 cases of primary aldosteronism diagnosed in women with postpartum hypertension, suggesting that this disorder is under-studied in the postpartum period. A review of these cases suggests that women with primary hyperaldosteronism commonly present with hypertensive disorders of pregnancy, but may only be identified de novo postpartum. However, a high index of suspicion is needed to diagnose primary hyperaldosteronism in the postpartum period, guided by a woman's obstetric history.

Ibuprofen and Postpartum Blood Pressure in Women With Hypertensive Disorders of Pregnancy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of ibuprofen on blood pressure in women with a diagnosis of hypertensive disorders of pregnancy and mild hypertension during the immediate postpartum period.

METHODS

In this double-blind controlled trial, we randomly assigned women with a diagnosis of hypertensive disorders of pregnancy and mild hypertension to receive a postpartum analgesic regimen with either ibuprofen or acetaminophen. The primary outcome was average mean arterial pressure during the postpartum hospital stay. Prespecified secondary outcomes included use of breakthrough opioid pain medications, length of hospital stay, and postpartum diuresis, defined as urine output of at least 200 mL/hour for 4 hours. A sample size of 56 participants was needed to detect a difference of 6 mm Hg in average mean arterial pressure between the study groups.

RESULTS

From January 17, 2017, to February 24, 2018, 61 participants were randomized and completed the trial, 31 participants in the ibuprofen group and 30 in the control group. Baseline characteristics were similar between groups. Postpartum average arterial pressure did not differ between study groups (93±8 mm Hg for those in the ibuprofen group vs 93±7 mm Hg in the control group, P=.93). Breakthrough opioid medications were requested by 24% of the participants in the ibuprofen group compared with 30% in the control group (P=.62). The ibuprofen group did not have a longer length of stay (48 hours vs 43 hours in the control group) or decreased rate of postpartum diuresis (61% in ibuprofen group vs 77% in the control group, P=.2).

CONCLUSION

In women with hypertensive disorders of pregnancy and mild hypertension, ibuprofen did not increase postpartum blood pressure compared with women not receiving nonsteroidal antiinflammatory drugs.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT03011567.

Torsemide for Prevention of Persistent Postpartum Hypertension in Women With Preeclampsia: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether torsemide reduces the rate of persistent postpartum hypertension in women with preeclampsia.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial of women with preeclampsia at a tertiary center from August 2016 to September 2017. Those with gestational hypertension or renal or cardiopulmonary failure were excluded. Within 24 hours of delivery, women were randomized one to one to oral torsemide, 20 mg/d, or placebo, for 5 days. Our primary outcome was blood pressure greater than or equal to 150 mm Hg systolic or 100 mm Hg diastolic (or both) on two occasions at least 4 hours apart by postpartum day 5 or by the time of hospital discharge. Assuming a 50% rate of persistent hypertension in women with preeclampsia, 118 participants were required to detect a 50% rate reduction. Analyses were by intention to treat.

RESULTS

From August 2016 to September 2017, 118 women were randomized: 59 were allocated to torsemide and 59 to placebo. Overall, 43 (73%) women in the torsemide and 45 (76%) in the placebo group had either preeclampsia with severe features or preeclampsia superimposed on chronic hypertension. The rate of persistent postpartum hypertension was 44% in the torsemide and 58% in the placebo group (relative risk 0.76, 95% CI 0.5-1.1). No differences were seen in rate of hypertension 7-10 days or 6 weeks postpartum, severe hypertension, length of postpartum hospital stay, readmission for hypertension, or adverse events. There were no cases of severe composite morbidity or deaths.

CONCLUSION

In this trial of women with preeclampsia, a 5-day course of postpartum torsemide did not have a significant effect on the rate of postpartum hypertension.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02813551.

Evaluation of selected cardiopulmonary and perceived exertion responses to four infant carrying methods utilised by African Mothers

Various infant carrying methods (ICMs) are utilised for childcare. Effects of these ICMs on the cardiopulmonary system are not known. This study evaluated cardiopulmonary and perceptual responses to four ICMs (back, front, side and in-arms) among 30 young females (18-35 years) while walking with a 6 kg simulated infant. Diastolic blood pressure (BP) responses were significantly different (p = .009) across the four ICMs, with the back ICM eliciting highest response. Heart rate, respiratory rate and systolic BP responses were not significantly different (p > .05) across the ICMs. Participants perceived the in-arms ICM as the most exerting. Body weight (p = .036) and body mass index (BMI) (p = .011) significantly correlated with systolic BP responses during the side ICM while age significantly (p = .036) correlated with heart rate changes during the in-arms ICM. Back ICM may pose more risk of diastolic BP dysfunctions. Increased body weight and BMI result in decreased systolic BP responses. IMPACT STATEMENT What is already known on this subject? Infant carrying (IC) has been associated with increased energy cost, biomechanical changes and musculoskeletal injuries. There is paucity of data on the cardiopulmonary responses to IC. What do the results of this study add? Back ICM resulted in higher responses in diastolic blood pressure. During the side ICM, participants' systolic BP decreased with increasing body weight and BMI values. Increased age resulted to decreased heart rate responses during the in-arms ICM. What are the implications of these findings for clinical practice and/or further research? There is need for effective monitoring of the cardiopulmonary parameters during IC tasks, especially among women with cardiopulmonary dysfunctions. Women with diastolic dysfunctions should be discouraged from utilising the back ICM. It is necessary for further studies to evaluate infant carrying-related cardiopulmonary responses relative to various components of IC practices, including weight of infant, maternal anthropometric characteristics and duration of IC tasks during each infant carrying method.

The performance of pre-delivery serum concentrations of angiogenic factors in predicting postpartum antihypertensive drug therapy following abdominal delivery in severe preeclampsia and normotensive pregnancy

Background

The imbalance between circulating concentrations of anti- and pro-angiogenic factors is usually intense in preeclampsia with severe features (sPE). It is possible that pre-delivery circulating levels of angiogenic factors in sPE may be associated with postpartum antihypertensive drug requirements.

Objective

To determine the predictive association between maternal pre-delivery serum concentrations of angiogenic factors and the use of ≥3 slow- and/or a rapid-acting antihypertensive drug therapy in sPE on postpartum days zero to three following caesarean delivery.

Study design

Women with sPE (n = 50) and normotensive pregnancies (n = 90) were recruited prior to childbirth. Serum samples were obtained from each participant < 48 hours before delivery to assess the concentrations of placental growth factor (PIGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) using the Roche Elecsys platform. Each participant was followed up on postpartum days zero, one, two and three to monitor BP and confirm antihypertensive treatment. The optimal cut-off thresholds of sFlt-1/PIGF ratio from receiver operating characteristic curve predictive of the antihypertensive therapy were subjected to diagnostic accuracy assessment.

Results

The majority 58% (29/50) of sPE had multiple severe features of preeclampsia in the antenatal period with the commonest presentation being severe hypertension in 88% (44/50) of this group, followed by features of impending eclampsia which occurred in 42% (21/50). The median gestational age at delivery was 38 (Interquartile range, IQR 1) vs 36 (IQR 6) weeks, p < 0.001 in normotensive and sPE groups respectively. Notably, the median sFlt-1/PIGF ratio in normotensive and sPE groups were 7.3 (IQR 17.9) and 179.1 (IQR 271.2) respectively, p < 0.001. Of the 50 sPE participants, 34% (17/50) had early-onset preeclampsia. The median (IQR) of sFlt-1/PIGF in the early- and late-onset preeclampsia groups were 313.52 (502.25), and 166.59(195.37) respectively, p = 0.006. From postpartum days zero to three, 48% (24/50) of sPE received ≥ 3 slow- and/or a rapid-acting antihypertensive drug. However, the daily administration of ≥ 3 slow- and/or a rapid-acting antihypertensive drug in sPE were pre-delivery 26% (13/50), postpartum day zero 18% (9/50), postpartum day one 34% (17/50), postpartum day two 24% (12/50) and postpartum day three 20% (10/50). In sPE, the pre-delivery sFlt-1/PIGF ratio was predictive of administration of ≥3 slow- and/or a rapid-acting antihypertensive drug on postpartum days zero, one and two with the optimal cut-off ratio being ≥315.0, ≥181.5 and ≥ 267.8 respectively (sensitivity 72.7–75.0%, specificity 64.7–78.6%, positive predictive value 40.0–50.0% and negative predictive value 84.6% - 94.3%). The predictive performance of sFlt-1/PIG ratio on postpartum day 3 among the sPE was not statistically significant (area under receiver operating characteristic curve, 0.6; 95% CI, 0.3–0.8).

Conclusion

A pre-delivery sFlt-1/PIGF ratio (< 181.5) is a promising predictor for excluding the need for ≥3 slow- and/or a rapid-acting antihypertensive drug therapy in the immediate postpartum period in sPE.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Preeclampsia/Eclampsia

OBJECTIVE

To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from preeclampsia/eclampsia by the California Pregnancy-Associated Mortality Review Committee.

DESIGN

Qualitative descriptive design using thematic analysis.

SAMPLE

A total of 242 QIOs identified from 54 cases of pregnancy-related deaths from preeclampsia/eclampsia in California between 2002 and 2007.

METHODS

We coded and thematically organized the 242 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.

RESULTS

Standardized Policies and Protocols to manage severe hypertension and respond to obstetric emergencies was the main theme identified in the Readiness domain. For Recognition, issues related to Missed Clinical Warning Signs of worsening preeclampsia/eclampsia were predominant. In the Response domain, the themes Inadequate Assessment and Treatment of severe hypertension and Coordination of Care were most frequently noted.

CONCLUSION

Findings from our study suggest numerous opportunities to improve care and outcomes for women who died of preeclampsia/eclampsia in California from 2002 to 2007. Facilities need to adopt and implement standardized policies and protocols about the diagnosis and treatment of preeclampsia/eclampsia. Clinician education about key warning signs is critical, as is ensuring that women understand the signs and symptoms that warrant immediate clinical attention. Death from preeclampsia/eclampsia is very preventable, and efforts to reduce maternal mortality and morbidity from this serious condition of pregnancy are needed at all levels.

Pilot study: placental biomarker predictive capability (sFlt-1, PlGF and their ratio) of postpartum maternal outcome

BACKGROUND

Prenatal measurement of placental biomarkers was able to improve screening and diagnosis of preeclampsia. Little is known about the clinical role of placental biomarkers in the postpartum period.

METHODS

This study is a prospective monocentric trial that included a total of 30 women with preeclamptic pregnancies. Serum placental biomarkers including soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF) were measured before and 2 h after delivery by Enzyme-Linked Immunosorbent Assay (ELISA) using commercially available kits according to manufacturer's instructions and correlated with the postpartum outcome.

RESULTS

Postpartum higher serum PlGF level was associated with postpartum elevation of the systolic blood pressure. Yet, the placental biomarkers were not able to predict general worsening of postpartum preeclampsia or other individual clinical or laboratory parameters.

CONCLUSION

Serum concentrations of sFlt-1 and PlGF or their ratio in our study cohort did not completely predict the occurrence of postpartum preeclampsia. Yet, postpartum higher serum PlGF level was associated with postpartum elevation of the systolic blood pressure.

The incidence of pregnancy hypertension in India, Pakistan, Mozambique, and Nigeria: A prospective population-level analysis

BACKGROUND

Most pregnancy hypertension estimates in less-developed countries are from cross-sectional hospital surveys and are considered overestimates. We estimated population-based rates by standardised methods in 27 intervention clusters of the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials.

METHODS AND FINDINGS

CLIP-eligible pregnant women identified in their homes or local primary health centres (2013-2017). Included here are women who had delivered by trial end and received a visit from a community health worker trained to provide supplementary hypertension-oriented care, including standardised blood pressure (BP) measurement. Hypertension (BP ≥ 140/90 mm Hg) was defined as chronic (first detected at <20 weeks gestation) or gestational (≥20 weeks); pre-eclampsia was gestational hypertension plus proteinuria or a pre-eclampsia-defining complication. A multi-level regression model compared hypertension rates and types between countries (p < 0.05 considered significant). In 28,420 pregnancies studied, women were usually young (median age 23-28 years), parous (53.7%-77.3%), with singletons (≥97.5%), and enrolled at a median gestational age of 10.4 (India) to 25.9 weeks (Mozambique). Basic education varied (22.8% in Pakistan to 57.9% in India). Pregnancy hypertension incidence was lower in Pakistan (9.3%) than India (10.3%), Mozambique (10.9%), or Nigeria (10.2%) (p = 0.001). Most hypertension was diastolic only (46.4% in India, 72.7% in Pakistan, 61.3% in Mozambique, and 63.3% in Nigeria). At first presentation with elevated BP, gestational hypertension was most common diagnosis (particularly in Mozambique [8.4%] versus India [6.9%], Pakistan [6.5%], and Nigeria [7.1%]; p < 0.001), followed by pre-eclampsia (India [3.8%], Nigeria [3.0%], Pakistan [2.4%], and Mozambique [2.3%]; p < 0.001) and chronic hypertension (especially in Mozambique [2.5%] and Nigeria [2.8%], compared with India [1.2%] and Pakistan [1.5%]; p < 0.001). Inclusion of additional diagnoses of hypertension and related complications, from household surveys or facility record review (unavailable in Nigeria), revealed higher hypertension incidence: 14.0% in India, 11.6% in Pakistan, and 16.8% in Mozambique; eclampsia was rare (<0.5%).

CONCLUSIONS

Pregnancy hypertension is common in less-developed settings. Most women in this study presented with gestational hypertension amenable to surveillance and timed delivery to improve outcomes.

TRIAL REGISTRATION

This study is a secondary analysis of a clinical trial - ClinicalTrials.gov registration number NCT01911494.