Postpartum evaluation and long term implications

Impact of a Women's Heart Clinic on Cardiovascular Disease Risk Awareness in Women with Past Pregnancy Complications: A Prospective Cohort Study

BACKGROUND

Gestational diabetes mellitus (GDM), hypertension during pregnancy (HDP) and/or having small-for-gestational-age (SGA) babies increase cardiovascular disease (CVD) risk. We investigated CVD risk awareness in women with past pregnancy complications and the impact of attending a Women's Heart Clinic (WHC) on this awareness.

METHOD

Women aged 30-55 years with past GDM, HDP and/or SGA babies were prospectively recruited into a 6-month WHC delivering education and management of CVD risk factors (Melbourne, Australia). A nine-item CVD risk Awareness Survey, consisting of six general/three female-specific questions, was administered at baseline and 6-month follow-up. The primary outcome was a change in overall CVD risk awareness before and after attending a WHC, analysed using a McNemar test. Logistic regression assessed for associations between CVD risk awareness and lifestyle behaviours.

RESULTS

A total of 156 women (mean age 41.0±4.2 years, 3.9±2.9 years postpartum) were recruited with 60.3% past GDM, 23.1% HDP, 13.5% both HDP/GDM and 3.2% SGA babies. The majority were White (68.6%), tertiary-educated (79.5%), and from higher income (84.6%). At baseline, 19.2% (95% confidence interval [CI] 13.0%-25.4%) of women had high overall CVD risk awareness, while 63.5% (95% CI 55.9%-71.0%) had high female-specific CVD risk awareness. At 6-month follow-up, overall CVD risk awareness (19.2%-76.1%, p<0.001) and female-specific CVD risk awareness (63.5%-94.8%; p<0.001) significantly increased. Improvement in CVD risk awareness was not associated with higher physical activity (adjusted odds ratio 0.49; 95% CI 0.04-3.21; p=0.51) or heart-healthy diet (adjusted odds ratio 2.49; 95% CI 0.88-6.93; p=0.08) at 6-month follow-up.

CONCLUSIONS

Attendance at a WHC significantly increased women's CVD risk awareness, however, this did not independently associate with lifestyle behaviours.

Influence of drug-related problems on length of hospital stay of women with a history of preeclampsia: A multicenter study

BACKGROUND

Approximately 5-7 % of pregnant women have hypertension during pregnancy, requiring antihypertensive drug treatment. There have been a lack of studies evaluating how drug-related problems (DRPs) affect morbidity or mortality in the postpartum period among women with a history of preeclampsia.

OBJECTIVE

To determine the influence of drug-related problems on length of hospital stay of postpartum women with a history of preeclampsia.

METHODS

This cross-sectional study included postpartum women diagnosed with preeclampsia, from June to November 2016, in two teaching maternity hospitals in Brazil. The outcomes assessed were, length of hospital stay of postpartum women. The DRPs were classified through the Pharmaceutical Care Network Europe Foundation (PCNE) v 8.01.

RESULTS

600 women were included, and 354 (59%) were exposed to at least one DRP. The most frequent DRPs were no administration of the prescribed medication, lack of prescription of a medication, although the indication was clear, and ineffectiveness (unknown reason). In patients exposed to DRP, the average length of hospital stay after labour was 5.4 (S.D. 3.6) days versus 4.4 (S.D. 3.3) days in patients non-exposed to DRP (p = 0.0001). The period (in days) to achieve blood pressure control after labour was 4.5 (S.D. 3.5) 3.5 (S.D. 3.2), respectively (p = 0.0001). There were no deaths during the study.

CONCLUSION AND RELEVANCE

Drug-related problems significantly increased the length of hospital stay in postpartum women with a history of preeclampsia.

Interpregnancy and interbirth intervals and all-cause, cardiovascular-related and cancer-related maternal mortality: findings from a large population-based cohort study

INTRODUCTION

Scarce research is available regarding the association between interbirth intervals (IBI) and long-term maternal health outcomes, particularly cardiovascular disease (CVD) mortality. We aimed to assess whether IBIs were associated with all-cause, CVD-related and cancer-related mortality.

METHODS

We conducted a cohort study in the setting of the Jerusalem Perinatal Study. Women with at least two consecutive singleton live births in 1964-1976 (N=18 294) were followed through 2016. IBIs were calculated as the interval between women's first and second cohort birth. We estimated associations between IBIs and mortality using Cox's proportional hazards models, adjusting for age, parity, maternal education, maternal origin and paternal socioeconomic status. Date of last menstrual period was available for a subset of women. We assessed the interpregnancy interval (IPI) for these women and compared the models using IPI and IBI.

RESULTS

During 868 079 years of follow up (median follow-up: 49.0 years), 3337 women died. Women with IBIs <15 months had higher all-cause mortality rates (HR 1.18; 95% CI 1.05 to 1.33) compared to women with 33-month to 68-month IBIs (reference category). IBI and CVD mortality appeared to have a J-shaped association; IBIs of <15, 15-20, 21-2626-2632, 33-68 and ≥69 months had HRs of 1.44, 1.40, 1.33, 1.14, 1.00 and 1.30, respectively. No substantial association was found with cancer mortality. Models using IPIs and those using IBI were similar.

CONCLUSION

Our results support the WHO recommendations for IPIs of ≥24 months and add additional evidence regarding long-term CVD mortality.

Postpartum Interventions to Reduce Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: A Systematic Review

Introduction: Hypertensive disorders (HDP) affect ~7% of pregnancies. Epidemiological evidence strongly suggests HDP independently increases that individual's risk of later cardiovascular disease (CVD). Focus on reduction or mitigation of this risk has been limited. This review seeks to identify trialed interventions to reduce cardiovascular risk after HDP. Methods: Online medical databases were searched to identify full-text published results of randomized controlled trials (RCT) in women <10 years postpartum after HDP that trialed interventions to reduce cardiovascular risk. Outcomes sought included cardiovascular disease events, chronic hypertension, and other measures of cardiovascular risk such as obesity, smoking status, diet, and physical activity. Publications from January 2008 to July 2019 were included. Results: Two RCTs were identified. One, a trial of calcium vs. placebo in 201 women with calcium commenced from the first follow-up visit outside of pregnancy and continued until 20 weeks' gestation if another pregnancy occurred. A non-significant trend toward decreased blood pressure was noted. The second RCT of 151 women tested an online education programme (vs. general information to control group) to increase awareness of risk factors and personalized phone-based lifestyle coaching in women who had a preeclampsia affected pregnancy in the 5 years preceding enrolment. Significant findings included increase in knowledge of CVD risk factors, reported healthy eating and decreased physical inactivity, however adoption of a promoted heart healthy diet and physical activity levels did not differ significantly between groups. Several observational studies after HDP, and one meta-analysis of studies of lifestyle interventions not performed specifically after HDP but used to extrapolate likely benefits of lifestyle interventions, were identified which supported the use of lifestyle interventions. Several ongoing RCTs were also noted. Discussion: There is a paucity of intervention trials in the early years after HDP to guide evidence-based cardiovascular risk reduction in affected women. Limited evidence suggests lifestyle intervention may be effective, however degree of any risk reduction remains uncertain. Conclusion: Sufficiently powered randomized controlled trials of appropriate interventions (e.g., lifestyle behavior change, pharmacological) are required to assess the best method of reducing the risk of cardiovascular disease in this at-risk population of women.

A comprehensive postpartum follow-up health care program for women with history of preeclampsia: protocol for a mixed methods research

Background

Long-term postpartum follow-up is of great importance since women with preeclampsia history are at high risk of upcoming health complications. However, postpartum follow-up rates are poor. According to evidences, preeclampsia is not just a transient health problem; rather it causes short term and long term complications, which affect women’s life for years after delivery. Although it seems the problem is solved by the end of pregnancy, the follow-up of subjects should not be stopped after delivery. Postpartum is the best possible time to provide necessary care to these women who are at the risk of future complications. Due to importance of well-designed follow-up plan for women suffering preeclampsia, this study will carry out to provide a postpartum follow-up health care program for subjected women.

Methods

This study is a qualitative-quantitative mixed sequencing exploratory study that consists of three consecutive phases. In this study, following a qualitative approach, the researcher will explain the needs and strategies related to promoting the health of women with preeclampsia history in the postpartum period. By entering the second phase, the researcher will design a comprehensive follow-up health care program in the postpartum period in which, in addition to using the qualitative study results, related papers and texts will be also used. The proposed program is designed by a panel of experts based on prioritization guidelines. Finally, after passing different stages of program finalizing, its effectiveness on the lifestyle of women with preeclampsia history will be investigated in a semi-experimental study in the third phase of the study.

Discussion

It is expected conducting a mixed method study to design and execute an interventional program to follow up women with preeclampsia history improve their health status and well-being, while reducing their health care costs through prevention in various levels within the current structure of health care services. If this program is effective, it could be included in the postpartum health care guidelines.

Trial registration

IRCT20170927036445N2 Registered 10 March 2018.

Exploring Implementation of m-Health Monitoring in Postpartum Women with Hypertension

BACKGROUND

Preeclampsia is a hypertensive disorder in pregnancy where a patients' blood pressure and warning signs of worsening disease need to be closely monitored during pregnancy and the postpartum period.

INTRODUCTION

No studies have examined remote patient monitoring using mobile health (m-health) technologies in obstetrical care for women with preeclampsia during the postpartum period. Remote monitoring and m-health technologies can expand healthcare coverage to the patient's home. This may be especially beneficial to patients with chronic conditions who live far from a healthcare facility.

MATERIALS AND METHODS

The study was designed to identify and examine the potential factors that influenced use of m-health technology and adherence to monitoring symptoms related to preeclampsia in postpartum women. A sample of 50 women enrolled into the study. Two participants were excluded, leaving a total sample size of 48 women. Users were given m-health devices to monitor blood pressure, weight, pulse, and oxygen saturation over a 2-week period. Nonusers did not receive equipment. The nurse call center monitored device readings and contacted participants as needed. Both groups completed a baseline and follow-up survey.

RESULTS

Women who elected to use the m-health technology on average had lower levels of perceived technology barriers, higher facilitating condition scores, and higher levels of perceived benefits of the technology compared with nonusers. Additionally, among users, there was no statistical difference between full and partial users at follow-up related to perceived ease of use, perceived satisfaction, or perceived benefits.

DISCUSSION

This study provided a basis for restructuring the management of care for postpartum women with hypertensive disorders through the use of m-health technology.

CONCLUSION

Mobile health technology may be beneficial during pregnancy and the postpartum period for women with preeclampsia to closely manage and monitor their blood pressure and warning signs of worsening disease.

SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014

This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.

Pre-eclampsia: an update

Pre-eclampsia remains the second leading direct cause of maternal death, >99 % of which occurs in less developed countries. Over 90 percent of the observed reduction in pre-eclampsia-related maternal deaths in the UK (1952-2008) occurred with antenatal surveillance and timed delivery. In this review, we discuss the pathogenesis, diagnostic criteria, disease prediction models, prevention and management of pre-eclampsia. The Pre-eclampsia Integrated Estimate of RiSk (PIERS) models and markers of angiogenic imbalance identify women at incremental risk for severe pre-eclampsia complications. For women at high risk of developing pre-eclampsia, low doses of aspirin (especially if started <17 weeks) and calcium are evidence-based preventative strategies; heparin is less so. Severe hypertension must be treated and the Control of Hypertension In Pregnancy (CHIPS) Trial (reporting: 2014) will guide non-severe hypertension management. Magnesium sulfate prevents and treats eclampsia; there is insufficient evidence to support alternative regimens. Pre-eclampsia predicts later cardiovascular disease; however, at this time we do not know what to do about it.

Late-onset postpartum preeclampsia: a case study

Late-onset postpartum preeclampsia is atypical and potentially life-threatening. Diagnosis is frequently delayed because signs and symptoms of significant disease are subtle, thus, nurse practitioners should have a high index of suspicion. Immediate consultation, diagnosis, initial management, pathophysiology, and breastfeeding support are discussed as well as patient education and future health implications.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

OBJECTIVE

This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP).

EVIDENCE

The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.

Women with cardiovascular risk after preeclampsia: is there follow-up within the Unified Health System in Brazil?

OBJECTIVES

to identify women with cardiovascular risk, five years after a pre-eclampsic episode (PE), and identify the follow-up of these women within the Unified Health System (Sistema Único de Saúde--SUS), in the city of Natal/RN.

METHODS

a quantitative and exploratory study conducted at the Januário Cicco University Maternity Ward/RN. The sample consisted of 130 women, 65 with a PE episode and 65 who were normotensive.

RESULTS

we found statistical significance with regard to body mass index, weight, family history of cardiovascular disease (CVD) and cardiovascular complications when comparing women with previous PE to normotensive women. The groups were unaware of their cardiovascular risk factors and, in addition, they reported difficulties in accessing primary health care (PHC) services.

CONCLUSIONS

women with a PE history are at increased risk of developing CVD, unaware of late PE complications, and lacked customized care when compared to normotensive patients.

Post-partum evaluation of maternal cardiac function after severe preeclampsia

OBJECTIVE

To evaluate the post-partum maternal cardiac function in patients with history of severe preeclampsia.

METHODS

A series of women with previous singleton pregnancy complicated by severe preeclampsia underwent transthoracic echocardiography at 6-12 months from delivery. A group of women with previous uncomplicated pregnancy was selected as controls.

RESULTS

Sixteen women with history of severe preeclampsia were enrolled in the study group whereas 18 patients were selected as controls. In the study group systolic (p=0.002) and diastolic blood pressure (p=0.044) were significantly higher. Significant differences were observed in systolic left ventricular (LV) parameters, such as cardiac output (p=0.034), LV mass indexed to BSA (p=0.024) and longitudinal contraction, expressed by tissue Doppler (TD) S1 wave, which resulted relatively impaired in former preeclamptic women (p=0.049). As regards as diastolic parameters, pulsed Doppler A-wave velocity was increased (p=0.036). TD E-wave velocity was significantly lower in study group (p<0.001) and E/E1 ratio (E=peak early diastole transmitral wave velocity/E1=peak early diastolic velocity at mitral valve annulus at TD) was higher respect to controls (p<0.001).

CONCLUSIONS

LV contractility and diastolic function, although within normal reference ranges, show slight but significant impairment among women who experienced a severe preeclampsia. TD seems to be a sensible tool to identify these precocious signs of potential LV dysfunction.

Clonidine versus captopril for treatment of postpartum very high blood pressure: study protocol for a randomized controlled trial (CLONCAP)

BACKGROUND

The behavior of arterial blood pressure in postpartum of women with hypertension and pregnancy and the best treatment for very high blood pressure in this period still need evidence. The Cochrane systematic review assessing prevention and treatment of postpartum hypertension found only two trials (120 patients) comparing hydralazine with nifedipine and labetalol for the treatment of severe hypertension and did not find enough evidence to know how best to treat women with hypertension after birth. Although studies have demonstrated the effectiveness of treatment with captopril, side effects were reported. Because of these findings, new classes of antihypertensive drugs began to be administered as an alternative therapy. Data on the role of clonidine in this particular group of patients, its effects in the short and long term are still scarce in the literature.

OBJECTIVES

To determine the effectiveness of clonidine, compared to captopril, for the treatment of postpartum very high blood pressure in women with hypertension in pregnancy.

METHODS/DESIGN

The study is a triple blind randomized controlled trial including postpartum women with diagnosis of hypertension in pregnancy presenting very high blood pressure, and exclusion criteria will be presence of heart disease, smoking, use of illicit drugs, any contraindication to the use of captopril or clonidine and inability to receive oral medications.Eligible patients will be invited to participate and those who agree will be included in the study and receive captopril or clonidine according to a random list of numbers. The subjects will receive the study medication every 20 minutes until blood pressure is over 170 mmHg of systolic blood pressure and 110 mmHg diastolic blood pressure. A maximum of six pills a day for very high blood pressure will be administered. In case of persistent high blood pressure levels, other antihypertensive agents will be used.During the study the women will be subject to strict control of blood pressure and urine output. This proposal has already obtained approval of the local Institutional Review Board of the coordinating center (IMIP, Recife, Brazil) and of the National Council for Ethics in Research (CONEP) of the Brazilian Ministry of Health.

TRIAL REGISTRATION

Clinical Trials Register under the number NCT01761916.

Epigenetics and microRNAs in preeclampsia

Strong evidence suggests a potential link among epigenetics, microRNAs (miRNAs), and pregnancy complications. Much research still needs to be carried out to determine whether epigenetic factors are predictive in the pathogenesis of preeclampsia (PE), a life-threatening disease during pregnancy. Recently, the importance of maternal epigenetic features, including DNA methylation, histone modifications, epigenetically regulated miRNA, and the effect of imprinted or non-imprinted genes on trophoblast growth, invasion, as well as fetal development and hypertension in pregnancy, has been demonstrated in a series of articles. This article discusses the current evidence of this complicated network of miRNA and epigenetic factors as potential mechanisms that may underlie the theories of disease for PE. Translating these basic epigenetic findings to clinical practice could potentially serve as prognostic biomarkers for diagnosis in its early stages and could help in the development of prophylactic strategies.