Demographic and Clinical Predictors of Postpartum Blood Pressure Screening Attendance

Public health and system approach in eliminating disparities in hypertensive disorders and cardiovascular outcomes in non-Hispanic Black women across the pregnancy life course

Hypertension is one of the leading risk factors for cardiovascular disease. The ACC/AHA/Multisociety hypertension guideline covered all aspects of the recommendations for optimal blood pressure diagnosis and management to improve cardiovascular outcomes. Despite this, there remains a growing prevalence of hypertension within the United States, largely in non-Hispanic Black women at earlier stages of their life course. This highlights the evident racial disparities, but offers a targeted opportunity for improved outcomes. With hypertension increasingly seen in the antenatal and immediate postpartum period, and obstetrics societies weighing in on the need to alter pharmacotherapy initiation goals, national initiatives have purposefully targeted pregnant and postpartum women in an effort to improve outcomes. This same energy must also re-focus health care efforts across the entire health continuum. Public health and system strategies are in place to do so, with the strongest enforcing initiatives as early as childhood with a greater focus on primordial prevention.

Severe Hypertension in Pregnancy: Progress Made and Future Directions for Patient Safety, Quality Improvement, and Implementation of a Patient Safety Bundle

Hypertensive disorders of pregnancy account for approximately 5% of pregnancy-related deaths in the United States and are one of the leading causes of maternal morbidity. Focus on improving patient outcomes in the setting of hypertensive disorders of pregnancy has increased in recent years, and quality improvement initiatives have been implemented across the United States. This paper discusses patient safety and quality initiatives for hypertensive disorders of pregnancy, with an emphasis on progress made and a patient safety tool: the Alliance for Innovation on Maternal Health's Severe Hypertension in Pregnancy patient safety bundle. Future patient safety and quality directions for the treatment of hypertensive disorders of pregnancy will be reviewed.

Association of Race and Ethnicity and Social Factors With Postpartum Primary Care or Cardiology Follow-Up Visits Among Individuals With Preeclampsia

BACKGROUND

Preeclampsia is associated with increased cardiovascular morbidity and death. Primary care or cardiology follow-up, in complement to routine postpartum obstetric care, provides an essential opportunity to address cardiovascular risk. Prior studies investigating racial differences in the recommended postpartum follow-up have incompletely assessed the influence of social factors. We hypothesized that racial and ethnic differences in follow-up with a primary care provider or cardiologist would be modified by income and education.

METHODS AND RESULTS

We identified adult individuals with preeclampsia (September 2014 to September 2019) in a national administrative database. We compared occurrence of a postpartum visit with a primary care provider or cardiologist within 1 year after delivery by race and ethnicity using multivariable logistic regression models. We examined whether education or income modified the association between race and ethnicity and the likelihood of follow-up. Of 18 050 individuals with preeclampsia (aged 31.8±5.7 years), Black individuals (11.7%) had lower odds of primary care provider or cardiology follow-up within 1 year after delivery compared with White individuals (adjusted odds ratio, 0.77 [95% CI, 0.70-0.85]) as did Hispanic individuals (14.8%; adjusted odds ratio, 0.79 [95% CI, 0.73-0.87]). Black and Hispanic individuals with higher educational attainment were more likely to have follow-up than those with lower educational attainment (P for interaction=0.033) as did those in higher income brackets (P for interaction=0.006).

CONCLUSIONS

We identified racial and ethnic differences in primary care or cardiology follow-up in the year postpartum among individuals diagnosed with preeclampsia, a disparity that may be modified by social factors. Enhanced system-level interventions are needed to reduce barriers to follow-up care.

Planning for the forgotten fourth trimester of pregnancy: A parallel group randomized control trial to test a postpartum planning intervention vs. standard prenatal care

BACKGROUND

Black and brown birthing people experience persistent disparities in adverse maternal health outcomes, partially due to inadequate perinatal care. The goal of this study is to design and evaluate a patient-centered intervention for obstetric patients with one or more cardiometabolic risk factors for severe maternal morbidity [gestational diabetes, diabetes mellitus, hypertensive disorders of pregnancy (chronic hypertension, preeclampsia, eclampsia, or gestational hypertension), or preconception obesity (BMI > 30)] to promote postpartum visit attendance.

METHODS

To address identified unmet needs for postpartum support and barriers to postpartum care, we developed 20 thematic postpartum planning modules, each with corresponding patient educational materials, community resources, care coordination protocols, and clinician support tools (decision aids, electronic medical record prompts and fields). During prenatal care encounters, a research coordinator delivers the educational content (in English or Spanish), facilitates the participant's planning and shared decision-making, provides the participant with resources, and documents decisions in the electronic medical record. We will randomize 320 eligible patients with a 1:1 ratio to the intervention or standard prenatal care and evaluate the impact on postpartum visit attendance at 4-12 weeks and secondary outcomes (postpartum mental health, perceived future maternal and cardiometabolic risk, contraceptive use, primary care use, readmission, and patient satisfaction with care).

DISCUSSION

Through engagement with patients and community stakeholders, we developed a guideline-based, locally tailored intervention to address drivers of engagement with postpartum care for high-risk obstetric patients. If demonstrated to be effective, the educational materials and electronic medical record based-tool can be adapted to other settings.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov (NCT05430815) on June 23, 2022.

Postpartum Remote Blood Pressure Monitoring Using a Mobile App in Women with a Hypertensive Disorder of Pregnancy

BACKGROUND

Hypertensive disorders of pregnancy affect approximately 15% of pregnancies in the United States and are a leading cause of postpartum readmissions. Morbidity due to hypertension may be higher in the first several weeks postpartum. The ability to monitor blood pressure and intervene in the postpartum period is critical to reducing morbidity and mortality.

LOCAL PROBLEM

At WellSpan Health, hypertensive disorders were increasing and a leading cause of severe maternal morbidity and readmission.

INTERVENTIONS

A remote blood pressure monitoring app called BabyScripts™ myBloodPressure was implemented in September 2020. Prior to discharge postpartum, all patients with a diagnosis of a hypertensive disorder of pregnancy were given an automatic blood pressure cuff and instructions on how to monitor and track their blood pressure daily in the app.

RESULTS

A total of 1,260 patients were enrolled in the BabyScripts™ myBloodPressure module between September 2020 and July 2022 across five maternity hospitals. Of those enrolled 74% ( n = 938) entered seven or more blood pressures, and of those who entered at least one blood pressure 9% ( n = 107) entered at least one critical range blood pressure ( ≥ 150 mmHg systolic and or ≥ 100 mmHg diastolic).

CONCLUSION

Most women enrolled in the app were highly engaged and entered seven or more readings. Patients with critical blood pressures were identified; thus, the program has the potential to identify those at risk of severe complications. Barriers should be removed, and remote patient monitoring considered as a solution to improve postpartum assessment in patients with hypertensive disorders of pregnancy.

Identification of Distinct Risk Factors for Antepartum and Postpartum Preeclampsia in a High-Risk Safety-Net Hospital

OBJECTIVE

Postpartum preeclampsia (PE), defined as de novo PE that develops at least 48 hours following delivery, can be particularly dangerous as many patients are already discharged at that point. The goal of our study was to identify risk factors uniquely associated with the development of late postpartum preeclampsia (PPPE).

STUDY DESIGN

In a retrospective cohort study of deliveries between July 1, 2016 and June 30, 2018 at a safety-net hospital in Atlanta, Georgia, we used multinomial logistic regression models to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between demographic, medical, and obstetric factors and development of PE, categorized as a three-level outcome: no PE, antepartum/intrapartum preeclampsia (APE) (diagnosed prior to or < 48 hours of delivery), and late PPPE (diagnosed ≥ 48-hour postpartum).

RESULTS

Among 3,681 deliveries, women were primarily of ages 20 to 35 years (76.4%), identified as non-Hispanic Black (68.5%), and covered by public health insurance (88.6%). PE was diagnosed prior to delivery or within 48-hour postpartum in 12% (n = 477) of the study population, and 1.5% (57) developed PE greater than 48-hour postpartum. In the adjusted models, maternal age ≥ 35, race/ethnicity, nulliparity, a diagnosis of pregestational or gestational diabetes, and chronic hypertension were associated with increased odds of APE only, while maternal obesity (OR: 1.9; 95% CI: 1.0-3.5) and gestational hypertension (OR: 2.7; 95% CI: 1.5-4.8) were uniquely associated with PPPE. Multifetal gestations and cesarean delivery predicted both PPPE and APE; however, the association was stronger for PPPE.

CONCLUSION

Patients with obesity, gestational hypertension, multifetal gestations, or cesarean delivery may benefit from additional follow-up in the early postpartum period to detect PPPE.

KEY POINTS

· Late postpartum preeclampsia may go undetected, particularly in low-income patients.. · In a delivery cohort in Georgia, 1.5% of patients developed late postpartum preeclampsia.. · Maternal obesity and gestational hypertension were strongly associated only with late postpartum preeclampsia..

Association Between Recurrent Preeclampsia and Attendance at the Blood Pressure Monitoring Appointment After Birth

OBJECTIVE

To examine the association between recurrent preeclampsia and attendance at the standard of care blood pressure monitoring appointment after birth.

DESIGN

Retrospective cohort.

SETTING

Single Magnet-accredited hospital affiliated with an academic medical center.

PARTICIPANTS

Multiparous women who gave birth between 2010 and 2020 and were diagnosed with preeclampsia (N = 313).

METHODS

We divided participants into two groups: those with prior preeclampsia (n = 119) and those without prior preeclampsia (n = 194). Using logistic regression, we calculated unadjusted and adjusted odds ratios to estimate the association between attendance at the postpartum blood pressure (PPBP) monitoring appointment and prior preeclampsia. We also explored the relationship between attendance at the PPBP monitoring appointment and use of magnesium sulfate during labor and birth and the relationship between attendance at the PPBP monitoring appointment and use of maintenance antihypertensive medications.

RESULTS

In adjusted analysis, participants with prior preeclampsia were 66.4% less likely to attend the PPBP monitoring appointment compared with those without prior preeclampsia, adjusted OR = 0.34, 95% CI [0.18, 0.62]. Administration of magnesium sulfate during delivery admission and use of maintenance antihypertensive medications were not associated with a change in attendance at the PPBP appointment.

CONCLUSION

Further research on patient-perceived risk of recurrent preeclampsia and improvement of systems to facilitate postpartum follow-up is needed.

Prevention of Cardiovascular Disease in Women With Pregnancy-Related Risk Factors: A Prospective Women's Heart Clinic Study

Background Hypertensive disorders of pregnancy, gestational diabetes, and having a small-for-gestational-age baby are known to substantially increase a woman's risk of cardiovascular disease. Despite this, evidence for models of care that mitigate cardiovascular disease risk in women with these pregnancy-related conditions is lacking. Methods and Results A 6-month prospective cohort study assessed the effectiveness of a multidisciplinary Women's Heart Clinic on blood pressure and lipid control in women aged 30 to 55 years with a past pregnancy diagnosis of hypertensive disorders of pregnancy, gestational diabetes, or a small-for-gestational age baby in Melbourne, Australia. The co-primary end points were (1) blood pressure <140/90 mm Hg or <130/80 mm Hg if diabetes and (2) total cholesterol to high-density lipoprotein cholesterol ratio <4.5. The study recruited 156 women with a mean age of 41.0±4.2 years, 3.9±2.9 years from last delivery, 68.6% White, 20.5% South/East Asian, and 80.5% university-educated. The proportion meeting blood pressure target increased (69.2% to 80.5%, P=0.004), with no significant change in lipid targets (80.6% to 83.7%, P=0.182). Systolic blood pressure (-6.9 mm Hg [95% CI, -9.1 to -4.7], P<0.001), body mass index (-0.6 kg/m2 [95% CI, -0.8 to -0.3], P<0.001), low-density lipoprotein cholesterol (-4.2 mg/dL [95% CI, -8.2 to -0.2], P=0.042), and total cholesterol (-4.6 mg/dL [95% CI, -9.1 to -0.2] P=0.042) reduced. Heart-healthy lifestyle significantly improved with increased fish/olive oil (36.5% to 51.0%, P=0.012), decreased fast food consumption (33.8% to 11.0%, P<0.001), and increased physical activity (84.0% to 92.9%, P=0.025). Conclusions Women at high risk for cardiovascular disease due to past pregnancy-related conditions experienced significant improvements in multiple cardiovascular risk factors after attending a Women's Heart Clinic, potentially improving long-term cardiovascular disease outcomes. Registration URL: https://www.anzctr.org.au; Unique identifier: ACTRN12622000646741.

Risk factors associated with attendance at postpartum blood pressure follow-up visit in discharged patients with hypertensive disorders of pregnancy

BACKGROUND

This study aims to investigate the risk factors for not returning to postpartum blood pressure (BP) follow-up visit at different time points in postpartum discharged hypertensive disorders of pregnancy (HDP) patients. Likewise, females with HDP in China should have a BP evaluation continuously for at least 42 days postpartum and have BP, urine routine, and lipid and glucose screening for 3 months postpartum.

METHODS

This study is a prospective cohort study of postpartum discharged HDP patients. Telephone follow-up was conducted at 6 weeks and 12 weeks postpartum, the maternal demographic characteristics, details of labor and delivery, laboratory test results of patients at admission, and adherence to BP follow-up visits postpartum were collected. While logistic regression analysis was used to analyze the factors associated with not returning to postpartum BP follow-up visit at 6 weeks and 12 weeks after delivery, the receiver operating characteristic (ROC) curve was drawn to evaluate the model's predictive value for predicting not returning to postpartum BP visit at each follow-up time point.

RESULTS

In this study, 272 females met the inclusion criteria. 66 (24.26%) and 137 (50.37%) patients did not return for postpartum BP visit at 6 and 12 weeks after delivery. A multivariate logistic regression analysis identified education level of high school or below (OR = 3.71; 95% CI = 2.01-6.85; p = 0.000), maximum diastolic BP during pregnancy (OR = 0.97; 95% CI = 0.94-0.99; p = 0.0230)and delivery gestational age (OR = 1.12; 95% CI = 1.005-1.244; p = 0.040)as independent risk factors in predicting not returning to postpartum BP follow-up visit at 6 weeks postpartum, and education level of high school or below (OR = 3.20; 95% CI = 1.805-5.67; p = 0.000), maximum diastolic BP during pregnancy (OR = 0.95; 95% CI = 0.92-0.97; p = 0.000), delivery gestational age (OR = 1.13; 95% CI = 1.04-1.24; p = 0.006) and parity (OR = 1.63; 95% CI = 1.06-2.51; p = 0.026) as risk factors for not returning to postpartum BP follow-up visit at 12 weeks postpartum. The ROC curve analysis indicated that the logistic regression models had a significant predictive value for identify not returning to BP follow-up visit at 6 and 12 weeks postpartum with the area under the curve (AUC) 0.746 and 0.761, respectively.

CONCLUSION

Attendance at postpartum BP follow-up visit declined with time for postpartum HDP patients after discharge. Education at or below high school, maximum diastolic BP during pregnancy and gestational age at delivery were the common risk factors for not returning for BP follow-up visit at 6 and 12 weeks postpartum in postpartum HDP patients.

Content Analysis of Patient-Facing Information Related to Preeclampsia

BACKGROUND

Previous research has shown pregnant people are not knowledgeable about preeclampsia, a significant cause of maternal morbidity and mortality. This lack of knowledge may impact their ability to report symptoms, comply with recommendations, and receive appropriate follow-up care. Pregnant people commonly seek information from sources outside their treating clinician, including pregnancy-specific books and online sources. We examined commonly used preeclampsia information sources to evaluate whether pregnant people are receiving up-to-date, guideline-based information.

METHODS

We conducted a content analysis of preeclampsia-related information in top-ranking websites and bestselling pregnancy books. We used American College of Obstetricians and Gynecologists preeclampsia guidelines to construct a codebook, which we used to examine source content completeness and accuracy. For each source, we analyzed information about preeclampsia diagnosis, patient-reported symptoms, risk factors, prevention, treatment, and complications.

RESULTS

Across 19 included sources (13 websites and 6 books), we found substantial variation in completeness and accuracy of preeclampsia information. We found high rates of mentions for preeclampsia symptoms. Risk factors were more commonly included in online sources than book sources. Most sources mentioned treatment options, including blood pressure medication and giving birth; however, one-third of online sources positively mentioned the nonrecommended treatment of bed rest. Prevention methods, including prenatal aspirin for high-risk pregnancies, and long-term complications of preeclampsia were infrequently mentioned.

CONCLUSIONS

Varying rates of accuracy in patient-facing preeclampsia information mean there is substantial room for improvement in these sources. Ensuring pregnant people receive current guideline-based information is critical for improving outcomes and implementing shared decision-making.

A Qualitative Study of Perceptions, Strengths, and Opportunities in Cardiometabolic Risk Management During Pregnancy and Postpartum in a Georgia Safety-Net Hospital, 2021

INTRODUCTION

Despite the strong link between cardiometabolic pregnancy complications and future heart disease, there are documented gaps in engaging those who experience such conditions in recommended postpartum follow-up and preventive care. The goal of our study was to understand how people in a Medicaid-insured population perceive and manage risks during and after pregnancy related to an ongoing cardiometabolic disorder.

METHODS

We conducted in-depth qualitative interviews with postpartum participants who had a cardiometabolic conditions during pregnancy (chronic or gestational diabetes, chronic or gestational hypertension, or preeclampsia). We recruited postpartum participants from a single safety-net hospital system in Atlanta, Georgia, and conducted virtual interviews during January through May 2021. We conducted a content analysis guided by the Health Belief Model and present themes related to risk management.

RESULTS

From the 28 interviews we conducted, we found that during pregnancy, advice and intervention by the clinical care team facilitated management behaviors for high-risk conditions. However, participants described limited understanding of how pregnancy complications might affect future outcomes, and few described engaging in postpartum management behaviors.

CONCLUSION

Improving continuity and content of care during postpartum may improve uptake of preventive behaviors among postpartum patients at risk of heart disease.