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Berhie SH, Little SE, Shulkin J, Seely EW, Nour NM, Wilkins-Haug L. Redesigning Care for the Management of Postpartum Hypertension: How Can Ob-Gyns and Primary Care Physicians Partner in Caring for Patients after a Hypertensive Pregnancy? Am J Perinatol 2024; 41:e1352-e1356. [PMID: 36882097 DOI: 10.1055/s-0043-1764207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
The standard care model in the postpartum period is ripe for disruption and attention. Hypertensive disorders of pregnancy (HDPs) can continue to be a challenge for the postpartum person in the immediate postpartum period and is a harbinger of future health risks. The current care approach is inadequate to address the needs of these women. We propose a model for a multidisciplinary clinic and collaboration between internal medicine specialists and obstetric specialists to shepherd patients through this high-risk time and provide a bridge for lifelong care to mitigate the risks of a HDP. KEY POINTS: · HDPs are increasing in prevalence.. · The postpartum period can be more complex for women with HDPs.. · A multidisciplinary clinic could fill the postpartum care gap for women with HDP..
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Affiliation(s)
- Saba H Berhie
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarah E Little
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jay Shulkin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Ellen W Seely
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nawal M Nour
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Louise Wilkins-Haug
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
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2
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Kraus AC, Quist-Nelson J, Ryan S, Stuebe A, Young OM, Volz E, Montiel C, Fiel L, Aktan I, Tully KP. Postpartum care in a cardio-obstetric clinic after preterm preeclampsia: patient and healthcare provider perspectives. Am J Obstet Gynecol MFM 2024; 6:101339. [PMID: 38492641 DOI: 10.1016/j.ajogmf.2024.101339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Despite the significant disruption and health implications of preterm preeclampsia with severe features for birthing people, little is known about how the system of postpartum care might be strengthened for affected families. Multidisciplinary cardio-obstetric clinics are emerging; however, there is limited research on patient and healthcare provider perspectives. OBJECTIVE To describe patient and healthcare provider perspectives of services in a cardio-obstetric clinic following preterm preeclampsia with severe features. STUDY DESIGN Individuals who experienced preterm preeclampsia with severe features and presented to a cardio-obstetric clinic were approached for study participation. Providers were approached if they provided postpartum care to patients with preterm preeclampsia with severe features and considered a referral to the cardio-obstetric clinic. Participants completed a remotely conducted, semistructured interview between March 2022 and April 2023. The interviews were audio-recorded, professionally transcribed, and checked for accuracy. Responses were inductively coded for content analysis around the study questions of clinical referrals, patient education, visit expectations, and care coordination in relation to ambulatory clinical services. RESULTS Twenty participants (n=10 patients and n=10 providers) completed interviews. Healthcare system navigation was difficult, particularly in the context of postpartum needs. When patients are informed about their diagnosis, the information could both increase anxiety and be useful for long-term healthcare planning. Language concordant care did not always occur, and both patients and providers described gaps in quality services. Within the theme of responsibility, patients described needing to be vigilant, and providers recognized the gaps in referral and care coordination systems. Comprehensible patient education provided with birthing parents' companions and enhanced systems for care coordination were areas for further improvement in providing postpartum cardio-obstetric care following preterm preeclampsia. CONCLUSION This qualitative study identified patients' struggles with a confusing postpartum healthcare system and captured providers' concerns about maintaining consistent care and improving access to long-term healthcare services to improve outcomes for patients at risk of cardiovascular disease.
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Affiliation(s)
- Alexandria C Kraus
- Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Kraus, Quist-Nelson, Ryan, Stuebe, Young, and Tully).
| | - Johanna Quist-Nelson
- Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Kraus, Quist-Nelson, Ryan, Stuebe, Young, and Tully)
| | - Stanthia Ryan
- Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Kraus, Quist-Nelson, Ryan, Stuebe, Young, and Tully)
| | - Alison Stuebe
- Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Kraus, Quist-Nelson, Ryan, Stuebe, Young, and Tully); Collaborative for Maternal and Infant Health, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Stuebe and Tully)
| | - Omar M Young
- Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Kraus, Quist-Nelson, Ryan, Stuebe, Young, and Tully)
| | - Elizabeth Volz
- Department of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Dr Volz)
| | - Catalina Montiel
- Department of Pediatrics, University of North Carolina at Chapel Hill (Mrs Montiel)
| | - Lauren Fiel
- UNC Health Rex, Raleigh, North Carolina (Mrs Fiel and Dr Aktan)
| | - Idil Aktan
- UNC Health Rex, Raleigh, North Carolina (Mrs Fiel and Dr Aktan)
| | - Kristin P Tully
- Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Kraus, Quist-Nelson, Ryan, Stuebe, Young, and Tully); Collaborative for Maternal and Infant Health, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Stuebe and Tully)
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3
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Paquin A, Wei J. Prediction of Preeclampsia: Time for the Cardiovascular Community to Be Involved. Can J Cardiol 2024; 40:431-433. [PMID: 38016542 DOI: 10.1016/j.cjca.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 11/30/2023] Open
Affiliation(s)
- Amélie Paquin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada; Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada; Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Malhamé I, Grandi SM. Cardiovascular mortality in the context of hypertensive disorders of pregnancy: Towards an optimisation of case identification strategies. Paediatr Perinat Epidemiol 2024; 38:216-218. [PMID: 38461821 DOI: 10.1111/ppe.13067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 02/21/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - Sonia M Grandi
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
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5
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Rosenberg EA, Seely EW. Long-term Cardiovascular Disease After Adverse Pregnancy Outcomes. J Clin Endocrinol Metab 2024; 109:e883-e891. [PMID: 37933906 DOI: 10.1210/clinem/dgad600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Indexed: 11/08/2023]
Abstract
Cardiovascular disease (CVD) is the leading cause of death among women. Adverse pregnancy outcomes (APOs) are cardiovascular risk factors that are unique to women and include gestational diabetes (GDM) and preeclampsia. While these risk factors emerge during the reproductive years and allow for early risk reduction counseling, they are often overlooked and not elicited by providers. This mini-review focuses primarily on GDM and preeclampsia, their relationship with CVD, mechanisms by which these conditions lead to CVD, and management, pharmacological and nonpharmacological, for the clinician who is caring for a woman with a history of an APO.
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Affiliation(s)
- Emily A Rosenberg
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Ellen W Seely
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
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Nix KM, Lee-Ann Hawkins T, Vlasschaert M, Ma IW, Nerenberg KA. Understanding Patient Perspectives on Specialized, Longitudinal, Postpartum, Cardiovascular Risk-Reduction Clinics. CJC Open 2024; 6:165-173. [PMID: 38487052 PMCID: PMC10935677 DOI: 10.1016/j.cjco.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/27/2023] [Indexed: 03/17/2024] Open
Abstract
Background Females who experience hypertensive disorders of pregnancy (HDP) have an increased lifelong risk of cardiovascular disease. Thus, Canadian clinical practice guidelines recommend cardiovascular risk reduction follow-up after a patient has HDP. This study examined the experiences of patients with HDP who attended a specialized, longitudinal general internal medicine postpartum cardiovascular risk reduction clinic called PreVASC. PreVASC focuses on comprehensive cardiovascular risk reduction through cardiovascular risk factor screening and management tailored specifically for female patients after they have HDP. Methods This multimethod study examined the experiences of female patients with HDP via the following: (i) a quantitative survey (summarized with descriptive statistics); (ii) semistructured qualitative patient phone interviews (results grouped thematically); and (iii) triangulation of qualitative themes with quantitative survey results. Results Overall, 37% of eligible clinic patients (42 of 115) participated; 79% of participants (n = 33) reported being "very satisfied" with the PreVASC clinic's specialized longitudinal model of care, and 95% (n = 40) reported making at least one preventive health behaviour change after receiving individualized counselling on cardiovascular risk reduction. Qualitative results found improvements in patient-reported cardiovascular health knowledge, health behaviours, and health-related anxiety. A preference for in-person vs phone clinic visits was reported by participants. Conclusions An in-person, general internal medicine specialist-led, longitudinal model of cardiovascular disease preventive care focused specifically on cardiovascular risk reduction after HDP had positive impacts on patient experience, health knowledge, and preventive health behaviours. This novel knowledge on patient preferences for a longitudinal, specialized model of care advances cardiovascular risk reduction tailored specifically for high-risk people after HDP.
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Affiliation(s)
- Kimberley M. Nix
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - T. Lee-Ann Hawkins
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meghan Vlasschaert
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Irene W.Y. Ma
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kara A. Nerenberg
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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7
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Arntzen E, Jøsendal R, Sandsæter HL, Horn J. Postpartum follow-up of women with preeclampsia: facilitators and barriers - A qualitative study. BMC Pregnancy Childbirth 2023; 23:833. [PMID: 38049716 PMCID: PMC10694896 DOI: 10.1186/s12884-023-06146-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/20/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Pregnancy causes physiological changes to the maternal organ systems that can be regarded as a cardiometabolic stress test for women. Preeclampsia, a pregnancy complication characterized by new onset of hypertension in combination with proteinuria or end-organ dysfunction, affects approximately 2-8% of pregnancies. Adverse pregnancy outcomes, including preeclampsia, have been described as a failed stress test and have been consistently linked with increased risk of cardiovascular disease later in life. The postpartum period is therefore often regarded as a window of opportunity for cardiovascular disease prevention. However, we lack knowledge about how women with preeclampsia experience current postpartum care in the Norwegian health system. The aim of this qualitative study is to uncover women's perspectives and preferences regarding postpartum follow-up. METHODS Semi-structured telephone interviews were conducted with 17 women following a six-month lifestyle intervention study. Participants were 9-20 months postpartum, following a pregnancy complicated by preeclampsia. Data were analyzed using Malterud's systematic text condensation. RESULTS We identified five themes, each with 2-3 subthemes, that demonstrate how women with recent preeclampsia experience postpartum follow-up: (1) fear and uncertainty (a body out of balance and facing an uncertain future), (2) a conversation on lifestyle - not really that difficult (preeclampsia as a gateway, a respectful approach, and a desire for more constructive feedback), (3) when your own health is not a priority (a new everyday life, out of focus, and lack of support), (4) motivation for lifestyle changes (an eye opener, lack of intrinsic motivation, and a helping hand), and (5) lack of structured and organized follow-up (there should be a proper system, a one-sided follow-up care, and individual variation in follow-up care). CONCLUSIONS Findings from this study highlight the need for more systematic postpartum follow-up for women after a pregnancy complicated by preeclampsia. Further research is required to explore the potential use of standardized guidelines and routine invitations to postpartum care. Furthermore, exploring health care professionals' experiences is crucial to ensure their engagement in postpartum care after complicated pregnancies.
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Affiliation(s)
- Eirin Arntzen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postbox 8905, NO-7491, Trondheim, Norway
| | - Ranveig Jøsendal
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postbox 8905, NO-7491, Trondheim, Norway
| | - Heidi Linn Sandsæter
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postbox 8905, NO-7491, Trondheim, Norway
- Department of Obstetrics and Gynecology, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Julie Horn
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postbox 8905, NO-7491, Trondheim, Norway.
- Department of Obstetrics and Gynecology, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.
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8
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Xu X, Du Y, Wang N. Association Between Circulating Resistin Level and Preeclampsia: A Meta-Analysis. Horm Metab Res 2023; 55:835-845. [PMID: 37793427 DOI: 10.1055/a-2167-0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Resistin, a diminutive secretory adipokine, has been linked to obesity and its related ailments. A growing body of evidence suggests that resistin may also be related to the pathogenesis preeclampsia. However, results of previous studies were not consistent. We performed a systematic review and meta-analysis to evaluate the level of circulating resistin in women with PE. A systematic search of Medline, Web of Science, and Embase databases from inception to April 28, 2023, was conducted to identify studies that compared blood resistin levels in pregnant women with and without PE. A random-effects model was utilized to pool the results, accounting for heterogeneity. The present study analyzed eighteen datasets from sixteen observational studies. The results of the meta-analysis demonstrated a statistically significant increase in blood resistin levels among women with PE compared to the control group. (standardized mean difference=0.35, 95% confidence interval: 0.16 to 0.54, p<0.001; I2=74%). The findings of the subgroup analysis indicate that various study characteristics, including study design, timing, and methods for measuring resistin, matching of body mass index between cases and controls, and study quality scores did not exert a significant impact on the outcomes. Nonetheless, it is noteworthy that the diagnostic criteria for PE employed in the studies included in the analysis may have influenced the results (p for subgroup difference=0.001). Women with preeclampsia exhibit a greater concentration of resistin in circulation when compared to healthy pregnant controls.
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Affiliation(s)
- Xiangyu Xu
- Department of Gynaecology and Obstetrics, Hangzhou Linping District First People's Hospital, Hangzhou, China
| | - Yi Du
- Department of Gynaecology and Obstetrics, Hangzhou Linping District First People's Hospital, Hangzhou, China
| | - Ni Wang
- Department of Gynaecology and Obstetrics, Hangzhou Linping District First People's Hospital, Hangzhou, China
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Roberts JM, King TL, Barton JR, Beck S, Bernstein IM, Buck TE, Forgues-Lackie MA, Facco FL, Gernand AD, Graves CR, Jeyabalan A, Hauspurg A, Manuck TA, Myers JE, Powell TM, Sutton EF, Tinker E, Tsigas E, Myatt L. Care plan for individuals at risk for preeclampsia: shared approach to education, strategies for prevention, surveillance, and follow-up. Am J Obstet Gynecol 2023; 229:193-213. [PMID: 37120055 DOI: 10.1016/j.ajog.2023.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/01/2023]
Abstract
Preeclampsia is a multisystemic disorder of pregnancy that affects 250,000 pregnant individuals in the United States and approximately 10 million worldwide per annum. Preeclampsia is associated with substantial immediate morbidity and mortality but also long-term morbidity for both mother and offspring. It is now clearly established that a low dose of aspirin given daily, beginning early in pregnancy modestly reduces the occurrence of preeclampsia. Low-dose aspirin seems safe, but because there is a paucity of information about long-term effects on the infant, it is not recommended for all pregnant individuals. Thus, several expert groups have identified clinical factors that indicate sufficient risk to recommend low-dose aspirin preventive therapy. These risk factors may be complemented by biochemical and/or biophysical tests that either indicate increased probability of preeclampsia in individuals with clinical risk factors, or more importantly, identify increased likelihood in those without other evident risk. In addition, the opportunity exists to provide this population with additional care that may prevent or mitigate the short- and long-term effects of preeclampsia. Patient and provider education, increased surveillance, behavioral modification, and other approaches to improve outcomes in these individuals can improve the chance of a healthy outcome. We assembled a group with diverse, relevant expertise (clinicians, investigators, advocates, and public and private stakeholders) to develop a care plan in which providers and pregnant individuals at risk can work together to reduce the risk of preeclampsia and associated morbidities. The plan is for care of individuals at moderate to high risk for developing preeclampsia, sufficient to receive low-dose aspirin therapy, as identified by clinical and/or laboratory findings. The recommendations are presented using the GRADE methodology with the quality of evidence upon which each is based. In addition, printable appendices with concise summaries of the care plan's recommendations for patients and healthcare providers are provided. We believe that this shared approach to care will facilitate prevention of preeclampsia and its attendant short- and long-term morbidity in patients identified as at risk for development of this disorder.
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Affiliation(s)
- James M Roberts
- Magee-Womens Research Institute and Clinical and Translational Science Institute, Department of Obstetrics, Gynecology and Reproductive Sciences and Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA.
| | - Tekoa L King
- School of Nursing, University of California, San Francisco, Oakland, CA
| | - John R Barton
- Maternal-Fetal Medicine, Baptist Health, Lexington, KY
| | - Stacy Beck
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Ira M Bernstein
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Burlington, VT
| | | | | | - Francesca L Facco
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Alison D Gernand
- Nutritional Sciences, Pennsylvania State University, University Park, PA
| | - Cornelia R Graves
- Division of Maternal-Fetal Medicine, University of Tennessee College of Medicine, Nashville, TN
| | - Arundhati Jeyabalan
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Tracy A Manuck
- Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jenny E Myers
- Division of Developmental Biology and Medicine, University of Manchester, Manchester, United Kingdom
| | - Trashaun M Powell
- National Racial Disparity Taskforce, Preeclampsia Foundation and New Jersey Family Planning League, Somerset, NJ
| | | | | | | | - Leslie Myatt
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
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10
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Burgess A, Stover S. Improving Cardiovascular Follow-Up after Diagnosis of a Hypertensive Disorder of Pregnancy using the Electronic Health Record. MCN Am J Matern Child Nurs 2023; 48:127-133. [PMID: 36744856 DOI: 10.1097/nmc.0000000000000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death among women. Sex-specific risk factors for cardiovascular disease include history of a hypertensive disorder of pregnancy. PROBLEM After diagnosis of a hypertensive disorder of pregnancy, professional societies recommend follow-up with a primary care provider for preventative care. There are gaps in patient and health care provider knowledge of the association between a hypertensive disorder of pregnancy and cardiovascular disease. That gap has a negative effect on patients receiving recommended follow-up. METHODS An electronic registry was created to identify those who gave birth in our health system and had a diagnosis of hypertensive disorder of pregnancy. From this, information outreach was sent electronically to the patient and their primary care provider. INTERVENTIONS Communication in the outreach included education on the association between hypertensive disorders of pregnancy and cardiovascular disease, the importance of follow-up, cardiopreventative strategies, and biochemical assessment. Medical records were audited at approximately 6 months postpartum to determine if patients completed a visit with their primary care provider to discuss cardiovascular risks. RESULTS Between May 2021 and June 2022, 15% ( n = 1,131) of patients who gave birth in our health system had a diagnosis of hypertensive disorder of pregnancy. Ninety percent of those patients who received outreach communication viewed the letter. At baseline, 16% of patients during postpartum with a hypertensive disorder of pregnancy saw their primary care provider to discuss cardiopreventative strategies. After implementation of our program, 26% of those with a hypertensive disorder of pregnancy saw their primary care provider for follow-up and discussed cardiopreventative strategies. CLINICAL IMPLICATIONS Nurses should ensure that women during postpartum and their primary care providers are educated about the association of hypertensive disorders of pregnancy and long-term cardiovascular risk. The electronic health record may be an optimal way to ensure education is provided and follow-up scheduled.
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Murray Horwitz ME, Prifti CA, Battaglia TA, Ajayi AT, Edwards CV, Benjamin EJ, Yarrington CD, Parker SE. Prepregnancy Cardiovascular Disease Risk Factors and Adverse Pregnancy Outcomes in a Safety-Net Hospital. J Womens Health (Larchmt) 2023; 32:401-408. [PMID: 36827080 PMCID: PMC10329150 DOI: 10.1089/jwh.2022.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Background: Many adverse pregnancy outcomes (APOs) are associated with elevated cardiovascular disease (CVD) risk. However, APO data in the context of pre-existing CVD risk factors, and from diverse populations, are limited. We assessed the occurrence of APOs among individuals with and without prepregnancy CVD risk factors, overall and by race/ethnicity. Methods: We conducted a retrospective study using electronic medical record data from a large urban safety-net hospital. Individuals with prenatal care and delivery between 2016 and 2018 at the hospital were included, and data from prenatal intake through the delivery hospitalization were captured. The exposure, prepregnancy CVD risk factors (hypertension, diabetes, tobacco use, and obesity), and the outcome, APOs (hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, low birth weight, and stillbirth), were identified from electronic medical records. Results: We identified 3760 unique delivering individuals, of whom 55.1% self-identified as Black non-Hispanic and 17% as Hispanic. Prepregnancy CVD risk factor prevalence was 45.6%, most commonly obesity (26.6%). APO prevalence was 35.6%, most commonly a hypertensive disorder of pregnancy (20.1%). Overall, 45.7% of APOs occurred in the absence of recognized prepregnancy CVD risk factors, representing 16.3% of the total sample. Among individuals without prepregnancy CVD risk factors, APO prevalence was 30.0% and did not vary by race/ethnicity. Conclusions: In this racially and ethnically diverse hospital-based sample, APOs were present in one in three parous individuals without prepregnancy CVD risk factors-a group with potentially elevated CVD risk who might otherwise be missed by traditional CVD risk factor screening.
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Affiliation(s)
- Mara E. Murray Horwitz
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Christine A. Prifti
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Tracy A. Battaglia
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Ayodele T. Ajayi
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Camille V. Edwards
- Section of Hematology/Oncology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Emelia J. Benjamin
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Christina D. Yarrington
- Department of Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Samantha E. Parker
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
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Abstract
Pre-eclampsia is a life-threatening disease of pregnancy unique to humans and a leading cause of maternal and neonatal morbidity and mortality. Women who survive pre-eclampsia have reduced life expectancy, with increased risks of stroke, cardiovascular disease and diabetes, while babies from a pre-eclamptic pregnancy have increased risks of preterm birth, perinatal death and neurodevelopmental disability and cardiovascular and metabolic disease later in life. Pre-eclampsia is a complex multisystem disease, diagnosed by sudden-onset hypertension (>20 weeks of gestation) and at least one other associated complication, including proteinuria, maternal organ dysfunction or uteroplacental dysfunction. Pre-eclampsia is found only when a placenta is or was recently present and is classified as preterm (delivery <37 weeks of gestation), term (delivery ≥37 weeks of gestation) and postpartum pre-eclampsia. The maternal syndrome of pre-eclampsia is driven by a dysfunctional placenta, which releases factors into maternal blood causing systemic inflammation and widespread maternal endothelial dysfunction. Available treatments target maternal hypertension and seizures, but the only 'cure' for pre-eclampsia is delivery of the dysfunctional placenta and baby, often prematurely. Despite decades of research, the aetiology of pre-eclampsia, particularly of term and postpartum pre-eclampsia, remains poorly defined. Significant advances have been made in the prediction and prevention of preterm pre-eclampsia, which is predicted in early pregnancy through combined screening and is prevented with daily low-dose aspirin, starting before 16 weeks of gestation. By contrast, the prediction of term and postpartum pre-eclampsia is limited and there are no preventive treatments. Future research must investigate the pathogenesis of pre-eclampsia, in particular of term and postpartum pre-eclampsia, and evaluate new prognostic tests and treatments in adequately powered clinical trials.
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13
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Wang S, Rexrode KM, Florio AA, Rich-Edwards JW, Chavarro JE. Maternal Mortality in the United States: Trends and Opportunities for Prevention. Annu Rev Med 2023; 74:199-216. [PMID: 36706746 DOI: 10.1146/annurev-med-042921-123851] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Maternal mortality is unusually high in the United States compared to other wealthy nations and is characterized by major disparities in race/ethnicity, geography, and socioeconomic factors. Similar to other developed nations, the United States has seen a shift in the underlying causes of pregnancy-related death, with a relative increase in mortality resulting from diseases of the cardiovascular system and preexisting medical conditions. Improved continuity of care aimed at identifying reproductive-age women with preexisting conditions that may heighten the risk of maternal death, preconception management of risk factors for major adverse pregnancy outcomes, and primary care visits within the first year after delivery may offer opportunities to address gaps in medical care contributing to the unacceptable rates of maternal mortality in the United States.
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Affiliation(s)
- Siwen Wang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA;
| | - Kathryn M Rexrode
- Division of Women's Health, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea A Florio
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA;
| | - Janet W Rich-Edwards
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge E Chavarro
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA; .,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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14
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Vygivska LA, Derevianchenko NV, Rudenko LA, Chebotenko OR. PREECLAMPSIA AND ITS EFFECT ON THE STATE OF CARDIOVASCULAR SYSTEM IN WOMEN. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:1826-1830. [PMID: 37740977 DOI: 10.36740/wlek202308118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
Abstract
OBJECTIVE The aim: To determine the features of the impact of preeclampsia on the development of cardiovascular disorders in women in the future. PATIENTS AND METHODS Materials and methods: The study involved an assessment of literary sources, which were published mainly in the last five years, using scientometric and specialized databases Pubmed, Science direct, Scopus, Web of Science, Google Scholar and V.I. Vernadskyi NLU "Scientific Periodicals of Ukraine". CONCLUSION Conclusions: Cardiovascular disorders are not only a medical problem, but also a social one. Preeclampsia is a dangerous condition that contributes to the development of CVDs, increases the rate of mortality and disability among women. All this makes it absolutely necessary to study the features of the pathogenesis in detail, to understand exactly how, through which mechanisms, the preeclamptic state affects the woman's body, and this will allow doctors to indirectly influence its pathogenesis and reduce negative consequences and improve the quality of life.
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Ishaku SM, Adu-Bonsaffoh K, Housseine N, Lamptey R, Franx A, Grobbee D, Warren CE, Browne JL. Prevention and Screening for Cardiometabolic Disease Following Hypertensive Disorders in Pregnancy in Low-Resource Settings: A Systematic Review and Delphi Study. Glob Heart 2023; 18:21. [PMID: 37125389 PMCID: PMC10143945 DOI: 10.5334/gh.1195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Hypertensive disorders in pregnancy (HDP) and cardiometabolic and kidney diseases are rising in low- and middle-income countries (LMICs). While HDP are risk factors for cardiometabolic and kidney diseases, cost-effective, scalable strategies for screening and prevention in women with a history of HDP are lacking. Existing guidelines and recommendations require adaptation to LMIC settings. This article aims to generate consensus-based recommendations for the prevention and screening of cardiometabolic and kidney diseases tailored for implementation in LMICs. We conducted a systematic review of guidelines and recommendations for prevention and screening strategies for cardiometabolic and chronic kidney diseases following HDP. We searched PubMed/Medline, Embase and Cochrane Library for relevant articles and guidelines published from 2010 to 2021 from both high-income countries (HICs) and LMICs. No other filters were applied. References of included articles were also assessed for eligibility. Findings were synthesized narratively. The summary of guiding recommendations was subjected to two rounds of Delphi consensus surveys with experts experienced in LMIC settings. Fifty-four articles and 9 guidelines were identified, of which 25 were included. Thirty-five clinical recommendations were synthesized from these and classified into six domains: identification of women with HDP (4 recommendations), timing of first counseling and provision of health education (2 recommendations), structure and care setting (12 recommendations), information and communication needs (5 recommendations), cardiometabolic biomarkers (8 recommendations) and biomarkers thresholds (4 recommendations). The Delphi panel reached consensus on 33 final recommendations. These recommendations for health workers in LMICs provide practical and scalable approaches for effective screening and prevention of cardiometabolic disease following HDP. Monitoring and evaluation of implementation of these recommendations provide opportunities for reducing the escalating burden of noncommunicable diseases in LMICs.
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Affiliation(s)
- Salisu Mohammed Ishaku
- Julius Global Health, Julius Center for Health Science and Primary Care, University Medical Center, Utrecht, NL
| | - Kwame Adu-Bonsaffoh
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
- Department of Obstetrics and Gynecology, University of Ghana Medical School, Korle Bu Teaching Hospital Accra, GH
| | - Natasha Housseine
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
- Medical College, Aga Khan University, Dar es Salaam, TZ
| | - Roberta Lamptey
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
- Department of Family Health, Korle Bu Teaching Hospital and Department of Community Health, GH
| | - Arie Franx
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, NL
| | - Diederick Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | | | - Joyce L. Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
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Louis JM, Parchem J, Vaught A, Tesfalul M, Kendle A, Tsigas E. Preeclampsia: a report and recommendations of the workshop of the Society for Maternal-Fetal Medicine and the Preeclampsia Foundation. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2022.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Purpose of Review Patients remain at risk for persistent and de novo postpartum hypertension related to pregnancy. This review aims to summarize the current definitions, clinical practices, and novel systems innovations and therapies for postpartum hypertension. Recent Findings Recent changes to the definitions of hypertension outside of pregnancy have not yet impacted definitions or management of hypertensive disorders of pregnancy (HDP), though research examining the implications of these new definitions on risks of developing HDP and the resultant sequelae is ongoing. The administration of diuretics has been shown to reduce postpartum hypertension among women with HDP. Widespread implementation of telemedicine models and remote assessment of ambulatory blood pressures has increased data available on postpartum blood pressure trajectories, which may impact clinical management. Additionally, policy changes such as postpartum Medicaid extension and an increasing emphasis on building bridges to primary care in the postpartum period may improve long-term outcomes for women with postpartum hypertension. Prediction models utilizing machine learning are an area of ongoing research to assist with risk assessment in the postpartum period. Summary The clinical management of postpartum hypertension remains focused on blood pressure control and primary care transition for cardiovascular disease risk reduction. In recent years, systemic innovations have improved access through implementation of new care delivery models. However, the implications of changing definitions of hypertension outside of pregnancy, increased data assessing blood pressure trajectories in the postpartum period, and the creation of new risk prediction models utilizing machine learning remain areas of ongoing research.
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Roth H, Morcos V, Roberts LM, Hanley L, Homer CSE, Henry A. Preferences of Australian healthcare providers regarding education on long-term health after hypertensive disorders of pregnancy: a qualitative study. BMJ Open 2022; 12:e055674. [PMID: 35618327 PMCID: PMC9137339 DOI: 10.1136/bmjopen-2021-055674] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore Australian healthcare providers' (HCPs') preferred content, format and access to education regarding long-term health after hypertensive disorder of pregnancy (HDP), in order to guide the development of education programmes. DESIGN AND SETTING A qualitative study using a framework analysis was undertaken. Registered HCP who were practising in Australia and previously completed a survey about long-term health after HDP were invited to participate. PARTICIPANTS Twenty HCP were interviewed, including midwives, specialist obstetrician/gynaecologists, general practitioners with a diploma in obstetrics and gynaecology, and cardiologists. PRIMARY AND SECONDARY OUTCOME MEASURES Exploration of preferred content, format and distribution of educational material post-HDP. RESULTS Twenty HCP were interviewed in April to May 2020. Four main categories were identified. 'Obtaining evidence-based information for own learning' addressing own learning with preference for multi-disciplinary education, preferably endorsed or facilitated by professional organisations. 'Optimising the referral process from hospital to community health services' was about the need for structured long-term follow-up to transition from hospital to community health and align with HDP guidelines. 'Facilitating women's health literacy' addressed the need for evidence-based, print or web-based material to assist risk discussions with women. 'Seizing educational opportunities' addressed the responsibility of all HCP to identify education opportunities to initiate key health discussions with women. CONCLUSIONS HCP provided ideas on content, format and access of education regarding long-term health post-HDP within the parameters of the Australian healthcare context. This evidence will guide educational developments for HCP on post-HDP health to ensure they can better care for women and families.
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Affiliation(s)
- Heike Roth
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Discipline of Women's Health, University of New South Wales Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Centre for Midwifery, Child and Family Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Veronica Morcos
- Discipline of Women's Health, University of New South Wales Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Lynne M Roberts
- Discipline of Women's Health, University of New South Wales Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Women's and Children's Health, Saint George Hospital, Kogarah, New South Wales, Australia
| | - Lisa Hanley
- Maternity Consumer, Saint George Hospital, Kogarah, New South Wales, Australia
| | - Caroline S E Homer
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Centre for Midwifery, Child and Family Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Maternal, Child and Adolescent Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Amanda Henry
- Discipline of Women's Health, University of New South Wales Faculty of Medicine and Health, Sydney, New South Wales, Australia
- Women's Health, The George Institute for Global Health, Newtown, New South Wales, Australia
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19
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Ackerman-Banks CM, Grechukhina O, Spatz E, Lundsberg L, Chou J, Smith G, Greenberg VR, Reddy UM, Xu X, O'Bryan J, Smith S, Perley L, Lipkind HS. Seizing the Window of Opportunity Within 1 Year Postpartum: Early Cardiovascular Screening. J Am Heart Assoc 2022; 11:e024443. [PMID: 35411781 PMCID: PMC9238464 DOI: 10.1161/jaha.121.024443] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Our objective was to assess new chronic hypertension 6 to 12 months postpartum for those with hypertensive disorder of pregnancy (HDP) compared with normotensive participants. Methods and Results We performed a prospective cohort study of participants with singleton gestations and no known preexisting medical conditions who were diagnosed with HDP compared with normotensive women with no pregnancy complications (non-HDP). Participants underwent cardiovascular risk assessment 6 to 12 months after delivery. Primary outcome was onset of new chronic hypertension at 6 to 12 months postpartum. We also examined lipid values, metabolic syndrome, prediabetes, diabetes, and 30-year cardiovascular disease (CVD) risk. Multivariable logistic regression was performed to assess the association between HDP and odds of a postpartum diagnosis of chronic hypertension while adjusting for parity, body mass index, insurance, and family history of CVD. There were 58 participants in the HDP group and 51 participants in the non-HDP group. Baseline characteristics between groups were not statistically different. Participants in the HDP group had 4-fold adjusted odds of developing a new diagnosis of chronic hypertension 6 to 12 months after delivery, compared with those in the non-HDP group (adjusted odds ratio, 4.60 [95% CI, 1.65-12.81]), when adjusting for body mass index, parity, family history of CVD, and insurance. Of the HDP group, 58.6% (n=34) developed new chronic hypertension. Participants in the HDP group had increased estimated 30-year CVD risk and were more likely to have metabolic syndrome, a higher fasting blood glucose, and higher low-density lipoprotein cholesterol. Conclusions Participants without known underlying medical conditions who develop HDP have 4-fold increased odds of new diagnosis of chronic hypertension by 6 to 12 months postpartum as well as increased 30-year CVD risk scores. Implementation of multidisciplinary care models focused on CVD screening, patient education, and lifestyle interventions during the first year postpartum may serve as an effective primary prevention strategy for the development of CVD.
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Affiliation(s)
| | - Olga Grechukhina
- Department of Obstetrics, Gynecology, & Reproductive Science Yale University New Haven CT
| | - Erica Spatz
- Section of Cardiovascular Medicine Yale University New Haven CT
| | - Lisbet Lundsberg
- Department of Obstetrics, Gynecology, & Reproductive Science Yale University New Haven CT
| | - Josephine Chou
- Section of Cardiovascular Medicine Yale University New Haven CT
| | - Graeme Smith
- Kingston General Hospital Kingston Ontario Canada
| | - Victoria R Greenberg
- Department of Obstetrics and Gynecology Medstar Georgetown University Hospital Washington DC
| | - Uma M Reddy
- Department of Obstetrics and Gynecology Columbia University New York NY
| | - Xiao Xu
- Department of Obstetrics, Gynecology, & Reproductive Science Yale University New Haven CT
| | - Jane O'Bryan
- Department of Obstetrics, Gynecology, & Reproductive Science Yale University New Haven CT
| | - Shelby Smith
- University of Connecticut School of Medicine Hartford CT
| | - Lauren Perley
- Department of Obstetrics, Gynecology, & Reproductive Science Yale University New Haven CT
| | - Heather S Lipkind
- Department of Obstetrics, Gynecology, & Reproductive Science Yale University New Haven CT
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20
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Bijl RC, Bangert SE, Shree R, Brewer AN, Abrenica-Keffer N, Tsigas EZ, Koster MPH, Seely EW. Patient journey during and after a pre-eclampsia-complicated pregnancy: a cross-sectional patient registry study. BMJ Open 2022; 12:e057795. [PMID: 35241475 PMCID: PMC8896051 DOI: 10.1136/bmjopen-2021-057795] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To gain insight into the patient journey through a pre-eclampsia-complicated pregnancy. DESIGN Cross-sectional patient registry study. SETTING Online patient registry initiated by the Preeclampsia Foundation. PARTICIPANTS Women with a history of pre-eclampsia enrolled in The Preeclampsia Registry (TPR). PRIMARY AND SECONDARY OUTCOME MEASURES Retrospective patient-reported experience measures concerning awareness of pre-eclampsia, timing and type of information on pre-eclampsia received, involvement in decision making regarding medical care, mental/emotional impact of the pre-eclampsia-complicated pregnancy and impact on future pregnancy planning. RESULTS Of 3618 TPR-participants invited to complete the Patient Journey questionnaire, data from 833 (23%) responders were available for analysis. Most responders were white (n=795, 95.4%) and lived in the USA (n=728, 87.4%). Before their pre-eclampsia diagnosis, 599 (73.9%) responders were aware of the term 'pre-eclampsia', but only 348 (43.7%) were aware of its associated symptoms. Women with a lower level of education were less likely to have heard of pre-eclampsia (OR 0.36, 95% CI 0.21 to 0.62). Around the time of diagnosis, 29.2% of responders did not feel involved in the decision making, which was associated with reporting a serious mental/emotional impact of the pre-eclampsia experience (OR 2.46, 95% CI 1.58 to 3.84). Over time, there was an increase in the proportion of women who were aware of the symptoms of pre-eclampsia (32.2% before 2011 to 52.5% after 2016; p<0.001) and in the proportion of responders stating they received counselling about the later-life health risks associated with pre-eclampsia (14.2% before 2011 to 25.6% after 2016; p=0.005). CONCLUSIONS This study demonstrates that improved patient education regarding pre-eclampsia is needed, that shared decision making is of great importance to patients to enhance their healthcare experience, and that healthcare providers should make efforts to routinely incorporate counselling about the later-life health risks associated with pre-eclampsia. TRIAL REGISTRATION NUMBER NCT02020174.
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Affiliation(s)
- Rianne C Bijl
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Sophie E Bangert
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Raj Shree
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Alina N Brewer
- Preeclampsia Foundation, Melbourne, Florida, USA
- Juneau Biosciences LLC, Salt Lake City, Utah, USA
| | | | | | - Maria P H Koster
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ellen W Seely
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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21
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Primary Care-Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review. J Gen Intern Med 2022; 37:912-921. [PMID: 34993867 PMCID: PMC8734553 DOI: 10.1007/s11606-021-07149-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/08/2021] [Indexed: 12/20/2022]
Abstract
Several common adverse pregnancy outcomes can reveal subclinical or latent cardiovascular disease (CVD) risk, transiently exposed through the physiologic stress of pregnancy. The year after pregnancy may be a singular opportunity to identify and initiate treatment for CVD risk, even before the onset of traditional CVD risk factors. However, clinical guidance regarding CVD risk management after adverse pregnancy outcomes is lacking. We therefore conducted a systematic review of US clinical practice guidelines and professional society recommendations to inform primary care-based CVD risk management after adverse pregnancy outcomes. We identified 13 relevant publications. While most recommendations were based on limited or weak evidence, we identified several areas of consensus. First, individuals with an adverse pregnancy outcome associated with future CVD are likely to benefit from CVD risk assessment-accompanied by education, counseling, and support for lifestyle modification-beginning within the first postpartum year. Second, among clinicians, clear and consistent documentation about adverse pregnancy outcomes and recommended follow-up is important to coordinate care after pregnancy. In addition, patients need to be informed about their pregnancy complications and associated CVD risks, so that they can make informed health care and lifestyle decisions. Finally, in general, CVD prevention in the year after an adverse pregnancy outcome focuses on lifestyle modification, reserving pharmacotherapy for the highest-risk patients and those with traditional CVD risk factors. While postpartum lifestyle interventions show promise for reducing CVD risk after adverse pregnancy outcomes, continued research to determine the optimal content, timing, and long-term effects of such interventions is needed.
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22
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Shah LM, Wand A, Ying W, Hays AG, Blumenthal RS, Barouch LA, Zakaria S, Sharma G. Prevention Starts in the Womb: Opportunities for Addressing Cardiovascular Risk Factors During Pregnancy and Beyond. Methodist Debakey Cardiovasc J 2021; 17:48-59. [PMID: 34824681 PMCID: PMC8588699 DOI: 10.14797/mdcvj.696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/01/2021] [Indexed: 12/31/2022] Open
Abstract
Early identification and mitigation of sex-specific cardiovascular disease risk factors is a potential trajectory-changing strategy to improve lifelong cardiovascular health in women. These sex-specific risk factors include adverse pregnancy outcomes, polycystic ovarian syndrome, and premature menopause. We start by discussing the impact and management of risk factors for adverse pregnancy outcomes as an upstream intervention for cardiovascular disease risk reduction and then address the long-term effect and mitigation of sex-specific risk factors for cardiovascular disease.
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Affiliation(s)
- Lochan M Shah
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Alison Wand
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Wendy Ying
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Allison G Hays
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | | | - Lili A Barouch
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Sammy Zakaria
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
| | - Garima Sharma
- Johns Hopkins University School Of Medicine, Baltimore, Maryland, US
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Roth H, Henry A, Roberts L, Hanley L, Homer CSE. Exploring education preferences of Australian women regarding long-term health after hypertensive disorders of pregnancy: a qualitative perspective. BMC Womens Health 2021; 21:384. [PMID: 34724948 PMCID: PMC8561910 DOI: 10.1186/s12905-021-01524-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) affect 5-10% of pregnant women. Long-term health issues for these women include 2-3 times the risk of heart attacks, stroke and diabetes, starting within 10 years after pregnancy, making long-term health after HDP of major public health importance. Recent studies suggest this knowledge is not being transferred sufficiently to women and how best to transmit this information is not known. This study explored women's preferred content, format and access to education regarding long-term health after HDP. METHODS This was a qualitative study and framework analysis was undertaken. Women with a history of HDP who had participated in a survey on long-term health after HDP were invited to participate in this study. During telephone interviews women were asked about preferences and priorities concerning knowledge acquisition around long-term health after HDP. RESULTS Thirteen women were interviewed. They indicated that they wanted more detailed information about long-term and modifiable risk factors. Their preference was to receive risk counselling from their healthcare provider (HCP) early after giving birth along with evidence-based, print or web-based information to take home. All women suggested more structured postnatal follow-up, with automated reminders for key appointments. Automated reminders should detail rationale for follow-up, recommended tests and discussion topics to be addressed at the appointment. CONCLUSION Our findings show that most participants wanted information soon after birth with all women wanting information within 12 months post birth, complemented with detailed take-home evidence. Participants indicated preference for structured follow-up via their HCP with automated alerts about the appointment and recommended tests. This evidence can be used to guide the development of education programs for women on health after HDP which may enhance knowledge, preventive health management and more generally improve women's health trajectories.
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Affiliation(s)
- Heike Roth
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.
| | - Amanda Henry
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
- Department Women's and Children's Health, St George Hospital, Kogarah, Sydney, NSW, 2217, Australia
| | - Lynne Roberts
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
- Department Women's and Children's Health, St George Hospital, Kogarah, Sydney, NSW, 2217, Australia
| | | | - Caroline S E Homer
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- Burnet Institute, Maternal, Child and Adolescent Health, Melbourne, VIC, Australia
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Executive summary: Workshop on Preeclampsia, January 25-26, 2021, cosponsored by the Society for Maternal-Fetal Medicine and the Preeclampsia Foundation. Am J Obstet Gynecol 2021; 225:B2-B7. [PMID: 34087228 DOI: 10.1016/j.ajog.2021.05.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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25
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Khosla K, Heimberger S, Nieman KM, Tung A, Shahul S, Staff AC, Rana S. Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: Recent Advances in Hypertension. Hypertension 2021; 78:927-935. [PMID: 34397272 PMCID: PMC8678921 DOI: 10.1161/hypertensionaha.121.16506] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with a history of hypertensive disorders of pregnancy (HDP) suffer higher rates of long-term cardiovascular events including heart failure, coronary artery disease, and stroke. Cardiovascular changes during pregnancy can act as a natural stress test, subsequently unmasking latent cardiovascular disease in the form of HDP. Because HDP now affect 10% of pregnancies in the United States, the American Heart Association has called for physicians who provide peripartum care to promote early identification and cardiovascular risk reduction. In this review, we discuss the epidemiology, pathophysiology, and outcomes of HDP-associated cardiovascular disease. In addition, we propose a multi-pronged approach to support cardiovascular risk reduction for women with a history of HDP. Additional research is warranted to define appropriate blood pressure targets in the postpartum period, optimize the use of pregnancy history in risk stratification tools, and clarify the effectiveness of preventive interventions. The highest rates of HDP are in populations with poor access to resources and quality health care, making it a major risk for inequity of care. Interventions to decrease long-term cardiovascular disease risk in women following HDP must also target disparity reduction.
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Affiliation(s)
- Kavia Khosla
- University of Chicago Pritzker School of Medicine, IL (K.K., S.H.)
| | - Sarah Heimberger
- University of Chicago Pritzker School of Medicine, IL (K.K., S.H.)
| | | | - Avery Tung
- Department of Anesthesia and Critical Care (A.T., S.S.), University of Chicago, IL
| | - Sajid Shahul
- Department of Anesthesia and Critical Care (A.T., S.S.), University of Chicago, IL
| | - Anne Cathrine Staff
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway (A.C.S.)
- Division of Obstetrics and Gynaecology, Oslo University Hospital, Norway (A.C.S.)
| | - Sarosh Rana
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL
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McCloskey L, Bernstein J, The Bridging The Chasm Collaborative, Amutah-Onukagha N, Anthony J, Barger M, Belanoff C, Bennett T, Bird CE, Bolds D, Brenna BW, Carter R, Celi A, Chachere B, Crear-Perry J, Crossno C, Cruz-Davis A, Damus K, Dangel A, Depina Z, Deroze P, Dieujuste C, Dude A, Edmonds J, Enquobahrie D, Eromosele E, Ferranti E, Fitzmaurice M, Gebel C, Blount LG, Greiner A, Gullo S, Haddad A, Hall N, Handler A, Headen I, Heelan-Fancher L, Hernandez T, Johnson K, Jones E, Jones N, Klaman S, Lund B, Mallampalli M, Marcelin L, Marshall C, Maynard B, McCage S, Mitchell S, Molina R, Montasir S, Nicklas J, Northrup A, Norton A, Oparaeke E, Ramos A, Rericha S, Rios E, Bloch JR, Ryan C, Sarfaty S, Seely E, Souter V, Spain M, Spires R, Theberge S, Thompson T, Wachman M, Yarrington T, Yee LM, Zera C, Clayton J, Lachance C. Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action. Womens Health Issues 2021; 31:204-218. [PMID: 33707142 PMCID: PMC8154664 DOI: 10.1016/j.whi.2021.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/09/2021] [Accepted: 01/12/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care. METHODS We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility. FINDINGS Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences. CONCLUSIONS The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.
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Affiliation(s)
- Lois McCloskey
- Community Health Sciences Department, Boston University School of Public Health, Boston, Massachusetts(b) The names and affiliations of all authors in the Bridging the Chasm Collaborative are listed in Table 1..
| | - Judith Bernstein
- Community Health Sciences Department, Boston University School of Public Health, Boston, Massachusetts(b) The names and affiliations of all authors in the Bridging the Chasm Collaborative are listed in Table 1
| | | | | | | | - Mary Barger
- University of San Diego, Hahn School of Nursing
| | | | - Trude Bennett
- University of North Carolina Gillings School of Global Public Health
| | | | | | | | | | - Ann Celi
- Brigham and Women's Hospital, Harvard Medical School
| | | | | | - Chase Crossno
- University of North Texas Health Sciences Center/Texas Christian University School of Medicine
| | | | - Karla Damus
- Boston University Medical Campus, Office of Human Research Affairs
| | | | | | | | | | - Annie Dude
- University of Chicago School of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | - Arden Handler
- University of Illinois at Chicago School of Public Health
| | - Irene Headen
- Drexel University Dornsife School of Public Health
| | | | | | | | - Emily Jones
- University of Oklahoma Health Sciences Center, Ziegler College of Nursing
| | | | - Stacey Klaman
- University of North Carolina Gillings School of Global Public Health
| | | | | | | | | | | | | | | | - Rose Molina
- Beth Israel Deaconess Medical Center / The Dimock Center
| | | | | | | | | | | | | | | | | | | | | | | | - Ellen Seely
- Brigham and Women's Hospital, Harvard Medical School
| | | | | | | | | | | | - Madi Wachman
- Boston University Center for Innovation in Social Work and Health
| | | | - Lynn M Yee
- Northwestern University, Feinberg School of Medicine
| | - Chloe Zera
- Beth Israel Deaconess Medical Center, Harvard Medical School
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McCloskey L, Amutah-Onukagha N, Bernstein J, Handler A. Setting the Agenda for Reproductive and Maternal Health in the Era of COVID-19: Lessons from a Cruel and Radical Teacher. Matern Child Health J 2021; 25:181-191. [PMID: 33411108 PMCID: PMC7788380 DOI: 10.1007/s10995-020-03033-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND COVID-19 exposes major gaps in the MCH safety net and illuminates the disproportionate consequences borne by people living in low resource communities where systemic racism, community disinvestment, and social marginalization creates a perfect storm of vulnerability. METHODS We draw eight lessons from the first 8 months of the pandemic, describing how COVID-19 has intensified pre-existing gaps in the MCH support network and created new problems. For each lesson identified, we present supporting evidence and a call for specific actions that can be taken by MCH practitioners, researchers and advocates. RESULTS LESSON #1: COVID-19 hits communities of color hardest, exposing and exacerbating health inequities caused by systemic racism. LESSON #2: Women experience the most devastating social, economic and mental health tolls during COVID-19. LESSON #3: Virulent pathogens find and exacerbate cracks in our public health and health care systems. LESSON #4: COVID-19 has become a pretext to limit access to sexual and reproductive health care. LESSON #5: COVID-19 has exposed and deepened fault lines in maternity care: over-medicalization, discrimination, lack of workforce diversity, underutilization of collaborative team approaches, and lack of post-delivery follow-up. LESSON #6: The pandemic adds impetus to much-needed Medicaid policy reforms that can have a lasting positive effect on maternal health. LESSON #7: Social and health policy changes, heretofore deemed infeasible, ARE possible under pandemic threat. LESSON #8: Finally, an overarching COVID-19 lesson: We are all inextricably connected. CONCLUSION COVID-19 is a loud wake up call for renewed action by MCH epidemiologists, policy-makers, and advocates.
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Affiliation(s)
- Lois McCloskey
- Department of Community Health Sciences, Center of Excellence in Maternal and Child Health Education, Science and Practice, Boston University School of Public Health, 801 Massachusetts Avenue | CT 436 |, Boston, MA 02118 USA
| | | | - Judith Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Arden Handler
- Division of Community Health Sciences and Center of Excellence in Maternal and Child Health, University of Illinois School of Public Health, 1603 W. Taylor, Chicago, IL 60612 USA
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28
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Grandi SM. Cardiovascular Risk Screening in Women with Pregnancy Complications: The Need for Integrative Strategies. J Womens Health (Larchmt) 2020; 30:285-286. [PMID: 32780667 DOI: 10.1089/jwh.2020.8716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Sonia M Grandi
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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