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Lemon LS, Venkatakrishnan K, Countouris M, Simhan H, Hauspurg A. Postpartum Weight Change Association With Readmission and Blood Pressure Trend Among Individuals With Hypertensive Disorders of Pregnancy. J Am Heart Assoc 2024; 13:e032820. [PMID: 38934854 PMCID: PMC11255696 DOI: 10.1161/jaha.123.032820] [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: 09/25/2023] [Accepted: 05/03/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The aim of this study was to evaluate the association between early postpartum weight change and (1) hospital readmission and (2) 2-week blood pressure trajectory. METHODS AND RESULTS This retrospective study cohort included 1365 individuals with a hypertensive disorder of pregnancy enrolled in a postpartum hypertension remote monitoring program. Exposure was percentage weight change from delivery to first weight recorded within 10 days postpartum. We first modeled likelihood of hospital readmission within 8 weeks postpartum using logistic regression adjusting for age, race, insurance, type of hypertensive disorder of pregnancy, early body mass index, gestational weight gain, mode of delivery, and any discharge antihypertensive medications. We then performed case-control analysis additionally matching in a 1:3 ratio on breastfeeding, early body mass index, discharge on antihypertensive medications, and days between weight measurements. Both analytic approaches were repeated, limiting to readmissions attributable to hypertension or heart failure. Finally, we compared blood pressure trajectories over first 2 weeks postpartum. Individuals who did not lose weight in the early postpartum period had more admissions compared with weight loss groups (group 3: 14.1% versus group 2: 5.8% versus group 1: 4.5%). These individuals had 4 times the odds of postpartum readmissions (adjusted odds ratio [aOR], 3.9 [95% CI, 1.8-8.6]) to 7 (aOR, 7.8 [95% CI, 2.3-26.5]) compared with those with the most weight loss. This association strengthened when limited to hypertension or heart failure readmissions. These individuals also had more adverse postpartum blood pressure trajectories, with significant differences by weight change group. CONCLUSIONS Weight change is readily accessible and may identify individuals at high risk for postpartum readmission following a hypertensive disorder of pregnancy who could benefit from targeted interventions.
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Affiliation(s)
- Lara S. Lemon
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee‐Womens HospitalUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of Clinical AnalyticsUniversity of Pittsburgh Medical CenterPittsburghPAUSA
- Magee‐Womens Research InstituteUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Kripa Venkatakrishnan
- Department of Clinical AnalyticsUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | - Malamo Countouris
- Division of Cardiology, Department of MedicineUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | - Hyagriv Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee‐Womens HospitalUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Magee‐Womens Research InstituteUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee‐Womens HospitalUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Magee‐Womens Research InstituteUniversity of Pittsburgh School of MedicinePittsburghPAUSA
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Gibson KS, Olson D, Lindberg W, Keane G, Keogh T, Ranzini AC, Alban C, Haddock J. Postpartum blood pressure control and the rate of readmission. Am J Obstet Gynecol MFM 2024; 6:101384. [PMID: 38768904 DOI: 10.1016/j.ajogmf.2024.101384] [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: 04/03/2024] [Revised: 04/20/2024] [Accepted: 04/26/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Postpartum hypertension is a major contributor to the rising maternal mortality rates in the United States, with nearly half of maternal deaths occurring after delivery. Previous studies have found evidence that the maximum blood pressure reading during labor and delivery admission can predict readmission; however, the optimal blood pressure to reduce the need for readmissions and additional medical treatment in the postpartum period is not known. OBJECTIVE This study aimed to investigate the relationship between postpartum blood pressure control at discharge and readmission within the first 6 weeks after delivery. STUDY DESIGN Data were obtained from Cosmos, an electronic health record-based, Health Insurance Portability and Accountability Act-defined limited dataset that includes more than 1.4 million birth encounters. All birthing parents with blood pressure data after delivery were included. Demographic information, medications, and readmissions were queried from the dataset. Patients were grouped into categories based on blood pressure readings in the 24 hours before discharge (≥160/110, ≥150/100, ≥140/90, ≥130/80, ≥120/80, and <120/80 mm Hg). The readmission rates across these groups were compared. Planned subanalyses included stratification by the use of antihypertensive medications and a sensitivity analysis using the highest blood pressure during admission. Covariates included maternal age, preexisting diabetes mellitus or lupus erythematosus, and body mass index. RESULTS The analysis included 1,265,766 total birth encounters, 391,781 (30.9%) in the referent group (120/80 mm Hg), 392,592 (31.0%) in the group with <120/80 mm Hg, 249,414 (19.7%) in the group with ≥130/80 mm Hg, 16,125 (1.3%) in the group with ≥140/90 mm Hg, 50,659 (4.0%) in the group with ≥150/100 mm Hg, and 20,196 (1.6%) in the group with ≥160/110 mm Hg. In the first 6 weeks after delivery, readmission rates increased with higher blood pressure readings. More than 5% of postpartum patients with the highest blood pressure readings (≥160/110 mm Hg) were readmitted. These patients were almost 3 times more likely to be readmitted than patients whose highest blood pressure reading fell into the referent group (120/80 mm Hg) (odds ratio [OR], 2.90; 95% confidence interval, 2.69-3.12). Patients with blood pressures of >150/100 mm Hg (odds ratio, 2.72; 95% confidence interval, 2.58-2.87), >140/90 mm Hg (odds ratio, 2.03; 95% confidence interval, 1.95-2.11), and >130/80 mm Hg (odds ratio, 1.43; 95% confidence interval, 1.37-1.49) all had higher odds of readmission, whereas patients with a blood pressure of <120/80 mm Hg had a lower odds of readmission (odds ratio, 0.78; 95% confidence interval, 0.75-0.81). Patients who had higher blood pressures during admission but had improved control in the 24 hours before discharge had lower rates of readmission than those whose blood pressures remained elevated. In all blood pressure categories, patients who received an antihypertensive prescription had higher rates of readmission. CONCLUSION In this large, national dataset, blood pressure control at discharge and readmission in the postpartum period were significantly correlated. Our data should inform postpartum hypertension treatment goals and the role of remote monitoring programs in improving maternal safety.
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Affiliation(s)
- Kelly S Gibson
- Division of Maternal-Fetal Medicine, Department of Reproductive Biology, The MetroHealth System/Case Western Reserve University, Cleveland, OH (Gibson, Olson, Lindberg, and Ranzini).
| | - Danielle Olson
- Division of Maternal-Fetal Medicine, Department of Reproductive Biology, The MetroHealth System/Case Western Reserve University, Cleveland, OH (Gibson, Olson, Lindberg, and Ranzini)
| | - Wesley Lindberg
- Division of Maternal-Fetal Medicine, Department of Reproductive Biology, The MetroHealth System/Case Western Reserve University, Cleveland, OH (Gibson, Olson, Lindberg, and Ranzini)
| | - Grant Keane
- Epic Corporation, Madison, WI (Keane, Keogh, Alban, and Haddock)
| | - Tim Keogh
- Epic Corporation, Madison, WI (Keane, Keogh, Alban, and Haddock)
| | - Angela C Ranzini
- Division of Maternal-Fetal Medicine, Department of Reproductive Biology, The MetroHealth System/Case Western Reserve University, Cleveland, OH (Gibson, Olson, Lindberg, and Ranzini)
| | | | - Joey Haddock
- Epic Corporation, Madison, WI (Keane, Keogh, Alban, and Haddock)
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Zhu KH, Lewandowski WL, Bisson CM, Suresh SC, Patel E, Mueller A, Silasi M, Rana S. Discharge medication delivery location and postpartum blood pressure control in patients with hypertensive disorders of pregnancy. Pregnancy Hypertens 2024; 36:101125. [PMID: 38669913 DOI: 10.1016/j.preghy.2024.101125] [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: 01/17/2024] [Revised: 04/06/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE This study examined whether use of bedside medication delivery (Meds to Beds, M2B) or on-campus pharmacy at discharge was associated with improved postpartum blood pressure (BP) control compared to outside pharmacy use in patients with hypertensive disorders of pregnancy (HDP). STUDY DESIGN This was a secondary analysis of 357 patients with HDP enrolled in STAMPP-HTN (Systematic Treatment and Management of Postpartum Hypertension Program) who were discharged from delivery admission with antihypertensives between October 2018 and June 2020. Patients were grouped by discharge medication location: M2B/on-campus pharmacy (on-site) versus outside pharmacy (off-site). MAIN OUTCOME MEASURES The primary outcome was BP values at the immediate postpartum visit. Secondary outcomes included six-week visit BP values, attendance at both visits, and readmission within six weeks. RESULTS Median BP values were no different based on pharmacy location at immediate postpartum visit for both systolic ((135 [IQR 127, 139] on-site vs 137 [127, 145] off-site, p = 0.22) and diastolic (81 [74, 91] vs 83 [76, 92], p = 0.45) values. Similar findings were noted at six weeks. Patients who used an off-site pharmacy had higher attendance rates at the immediate postpartum visit but this difference was attenuated after adjusting for group differences (OR 0.67 [95 % CI 0.37-1.20], p = 0.18). Readmission rates were also not different between groups (12.2 % on-site vs 15.8 % off-site pharmacy, p = 0.43). CONCLUSION In the context of a preexisting multicomponent HDP quality improvement program, on-campus pharmacy and bedside medication delivery use was not associated with additional improvement in postpartum BP control, follow-up rates, or readmission rates.
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Affiliation(s)
- Katherine H Zhu
- Department of Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, IL, USA
| | - Whitney L Lewandowski
- Department of Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, IL, USA
| | - Courtney M Bisson
- Department of Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, IL, USA
| | - Sunitha C Suresh
- Department of Obstetrics & Gynecology, Endeavor Health, Evanston, IL, USA
| | - Easha Patel
- Department of Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, IL, USA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle Silasi
- Department of Obstetrics & Gynecology, Mercy Hospital, St. Louis, MO, USA
| | - Sarosh Rana
- Department of Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, IL, USA.
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Viswanathan R, Little SE, Wilkins-Haug L, Seely EW, Berhie SH. The patient experience of a postpartum readmission for hypertension: a qualitative study. BMC Pregnancy Childbirth 2024; 24:358. [PMID: 38745136 PMCID: PMC11094995 DOI: 10.1186/s12884-024-06564-2] [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: 08/06/2023] [Accepted: 05/03/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are the most common cause of postpartum readmission. Prior research led to clinical guidelines for postpartum management; however, the patient experience is often missing from this work. The objective of this study is to understand the perspective of patients readmitted for postpartum hypertension. METHODS This was a qualitative study with data generated through semi-structured interviews. Patients readmitted with postpartum HDP at an urban academic medical center from February to December 2022 were approached and consented for an interview. The same researcher conducted all interviews and patient recruitment continued until thematic saturation was reached (n = 9). Two coders coded all interviews using Nvivo software with both deductive and inductive coding processes. Discrepancies were discussed and resolved with consensus among the two coders. Themes were identified through an initial a priori template of codes which were expanded upon using grounded theory, and researchers were reflexive in their thematic generation. RESULTS Six themes were generated: every pregnancy is different, symptoms of preeclampsia are easily dismissed or minimized by both patient and providers, miscommunication regarding medical changes can increase the risk of readmissions, postpartum care coordination and readmission logistics at our hospital could be improved to facilitate caring for a newborn, postpartum care is often considered separately from the rest of pregnancy, and patient well-being improved when conversations acknowledged the struggles of readmission. CONCLUSIONS This qualitative research study revealed patient-identified gaps in care that may have led to readmission for hypertensive disorders of pregnancy. The specific recommendations that emerge from these themes include addressing barriers to blood pressure management prior to discharge, improving postpartum discharge follow-up, providing newborn care coordination, and improving counseling on the risk of postpartum preeclampsia during discharge. Incorporating these patient perspectives in hospital discharge policy can be helpful in creating patient-centered systems of care and may help reduce rates of readmission.
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Affiliation(s)
- Radhika Viswanathan
- SUNY Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA.
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Hospital, New York, NY, USA.
| | - Sarah E Little
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Louise Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ellen W Seely
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Saba H Berhie
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
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Zhou L, Tian Y, Su Z, Sun JY, Sun W. Risk factors and prediction model for new-onset hypertensive disorders of pregnancy: a retrospective cohort study. Front Cardiovasc Med 2024; 11:1272779. [PMID: 38751664 PMCID: PMC11094209 DOI: 10.3389/fcvm.2024.1272779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Background and aims Hypertensive disorders of pregnancy (HDP) is a significant cause of maternal and neonatal mortality. This study aims to identify risk factors for new-onset HDP and to develop a prediction model for assessing the risk of new-onset hypertension during pregnancy. Methods We included 446 pregnant women without baseline hypertension from Liyang People's Hospital at the first inspection, and they were followed up until delivery. We collected maternal clinical parameters and biomarkers between 16th and 20th weeks of gestation. Logistic regression was used to determine the effect of the risk factors on HDP. For model development, a backward selection algorithm was applied to choose pertinent biomarkers, and predictive models were created based on multiple machine learning methods (generalised linear model, multivariate adaptive regression splines, random forest, and k-nearest neighbours). Model performance was evaluated using the area under the curve. Results Out of the 446 participants, 153 developed new-onset HDP. The HDP group exhibited significantly higher baseline body mass index (BMI), weight change, baseline systolic/diastolic blood pressure, and platelet counts than the control group. The increase in baseline BMI, weight change, and baseline systolic and diastolic blood pressure significantly elevated the risk of HDP, with odds ratios and 95% confidence intervals of 1.10 (1.03-1.17), 1.10 (1.05-1.16), 1.04 (1.01-1.08), and 1.10 (1.05-1.14) respectively. Restricted cubic spline showed a linear dose-dependent association of baseline BMI and weight change with the risk of HDP. The random forest-based prediction model showed robust performance with the area under the curve of 0.85 in the training set. Conclusion This study establishes a prediction model to evaluate the risk of new-onset HDP, which might facilitate the early diagnosis and management of HDP.
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Affiliation(s)
- Ling Zhou
- Department of Obstetrics and Gynecology, Liyang People's Hospital, Liyang, Jiangsu, China
| | - Yunfan Tian
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhenyang Su
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jin-Yu Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Kumar NR, Speedy SE, Song J, Welty LJ, Cavens AD. Quality Improvement Initiative for Aspirin Screening and Prescription Rates for Preeclampsia Prevention in an Outpatient Obstetric Clinic. Am J Perinatol 2024; 41:e917-e921. [PMID: 36584691 DOI: 10.1055/s-0042-1759705] [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: 01/01/2023]
Abstract
OBJECTIVE Hypertensive disorders of pregnancy (HDP) impact 10% of pregnancies in the United States and cause adverse maternal and neonatal outcomes such as prematurity and low birth weight. Aspirin administration to at-risk individuals during pregnancy can reduce risk of HDP. STUDY DESIGN Define-Measure-Assess-Improve-Control methodology was utilized to improve aspirin screening in an outpatient obstetric clinic. Retrospective cohort analysis compared outcome metrics pre- and postimplementation by using logistic regression models, adjusting for race and insurance. Key informant interviews and process mapping identified barriers to aspirin screening. A multidisciplinary team implemented low-cost strategies such as provider education, additional screening by ancillary staff, automated electronic reminders, and standardized patient counseling. RESULTS Over 6 months, the screening rate improved from 62.5 to 92.0% (adjusted odds ratio [aOR] = 6.89, 95% confidence interval [CI]: 3.30-14.43). The prescription rate for patients correctly identified to be eligible for aspirin improved from 66.7 to 82.4% (aOR = 1.96, 95% CI: 0.88-4.35). CONCLUSION Comprehensive, tailored quality improvement efforts can significantly increase aspirin screening and prescription, which may decrease maternal and neonatal morbidity due to HDP. KEY POINTS · Initiative improved overall and correct screening rates.. · Initiative increased provider knowledge of eligibility.. · Low-cost interventions can have high impact over short time interval..
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Affiliation(s)
- Natasha R Kumar
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sedona E Speedy
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jing Song
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leah J Welty
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Arjeme D Cavens
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Pressman K, Wellcome J, Pooran C, Crousillat D, Cain MA, Louis JM. Factors associated with early readmission for postpartum hypertension. AJOG GLOBAL REPORTS 2024; 4:100323. [PMID: 38919706 PMCID: PMC11197109 DOI: 10.1016/j.xagr.2024.100323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy are increasing in prevalence and a leading cause of early postpartum readmissions. Stricter blood pressure target goals for treatment of hypertension during pregnancy have recently been proposed, however, the treatment goals for management of postpartum hypertension are less well established. OBJECTIVE We sought to evaluate the clinical factors associated with early postpartum readmissions for hypertensive disease and to evaluate blood pressure thresholds associated with these readmissions. STUDY DESIGN We conducted a retrospective cohort study of women delivering at a tertiary care center between January 2018 and May 2022 who experienced a hospital readmission for postpartum hypertension or new onset postpartum preeclampsia. Charts were reviewed for clinical and sociodemographic data. Patients with early readmission (<72 hours after discharge) were compared with patients readmitted after 3 days of initial discharge. Data were analyzed using chi-square, Student t test, Mann-Whitney U test, and logistic regression where appropriate. The P value <.05 was considered significant. RESULTS During the study period, 23,372 deliveries occurred. Postpartum readmission due to worsening of a known diagnosis of hypertension or new onset postpartum preeclampsia occurred in 1.1% and 0.49% respectively. Patients with early readmission were more likely to have hypertensive disorders of pregnancy as the indication for delivery. Among patients readmitted, 93% had 2 or more systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg, and 73% had blood pressure of either systolic between 130 and 139 mmHg or diastolic between 80 and 89 mmHg within 24 hours before initial discharge. Only 27 patients met criteria (blood pressure ≥160/110 mmHg on >1 vitals check during their hospitalization) to be started on antihypertensives before initial delivery discharge; of those 25 (93%) were discharged with a new prescription for an antihypertensive. After controlling for confounding variables, predischarge blood pressure between 130-140 mmHg/80-90 mmHg (adjusted odds ratio, 2.4 [1.5-4.0]) was associated with an increased likelihood of early readmission. CONCLUSION Patients with delivery for hypertensive disorders of pregnancy and predischarge blood pressure ≥140/90 mmHg were less likely to have an early readmission within 3 days of initial discharge, however, patients with predischarge blood pressure 130-139 mmHg/80-89 mmHg were more likely to have an early readmission for hypertensive disorders of pregnancy and postpartum preeclampsia. Further research is indicated to evaluate interventions to prevent postpartum readmission in patients at high risk for persistent hypertension or new onset postpartum preeclampsia.
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Affiliation(s)
- Katherine Pressman
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL (Drs Pressman, Cain, and Louis)
| | - Jody Wellcome
- Morsani College of Medicine, University of South Florida, Tampa, FL (Dr Wellcome and Ms Pooran)
| | - Chandni Pooran
- Morsani College of Medicine, University of South Florida, Tampa, FL (Dr Wellcome and Ms Pooran)
| | - Daniela Crousillat
- Department of Cardiology, Morsani College of Medicine, University of South Florida, Tampa, FL (Dr Crousillat)
| | - Mary A. Cain
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL (Drs Pressman, Cain, and Louis)
| | - Judette M. Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL (Drs Pressman, Cain, and Louis)
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Lin BX, Smith M, Sutter M, Penfield CA, Proudfit C. Association between Peripartum Mean Arterial Pressure and Postpartum Readmission for Preeclampsia with Severe Features. Am J Perinatol 2024; 41:e2188-e2194. [PMID: 37385293 DOI: 10.1055/s-0043-1770705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE This study aimed to evaluate the relationship between peripartum mean arterial pressure (MAP) and postpartum readmission for preeclampsia with severe features. STUDY DESIGN This is a retrospective case-control study comparing adult parturients readmitted for preeclampsia with severe features to matched nonreadmitted controls. Our primary objective was to evaluate the association between MAP at three time points during the index hospitalization (admission, 24-hour postpartum, and discharge) and readmission risk. We also evaluated readmission risk by age, race, body mass index, and comorbidities. Our secondary aim was to establish MAP thresholds to identify the population at highest risk of readmission. Multivariate logistic regression and chi-squared tests were used to determine the adjusted odds of readmission based on MAP. Receiver operating characteristic analyses were performed to evaluate risk of readmission relative to MAP; optimal MAP thresholds were established to identify those at highest risk of readmission. Pairwise comparisons were made between subgroups after stratifying for history of hypertension, with a focus on readmitted patients with new-onset postpartum preeclampsia. RESULTS A total of 348 subjects met inclusion criteria, including 174 controls and 174 cases. We found that elevated MAP at both admission (adjusted odds ratio [OR]: 1.37 per 10 mm Hg, p < 0.0001) and 24-hour postpartum (adjusted OR: 1.61 per 10 mm Hg, p = 0.0018) were associated with increased risk of readmission. African American race and hypertensive disorder of pregnancy were independently associated with increased risk of readmission. Subjects with MAP > 99.5 mm Hg at admission or >91.5 mm Hg at 24-hour postpartum had a risk of at least 46% of requiring postpartum readmission for preeclampsia with severe features. CONCLUSION Admission and 24-hour postpartum MAP correlate with risk of postpartum readmission for preeclampsia with severe features. Evaluating MAP at these time points may be useful for identifying women at higher risk for postpartum readmission. These women may otherwise be missed based on standard clinical approaches and may benefit from heightened surveillance. KEY POINTS · Existing literature focuses on management of antenatal hypertensive disorders of pregnancy.. · Elevated peripartum MAP is associated with increased odds of readmission for preeclampsia.. · Peripartum MAP may predict readmission risk for de novo postpartum preeclampsia..
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Affiliation(s)
- Bing-Xue Lin
- Franciscan Women's Health Associates, Tacoma, Washington
| | - Maria Smith
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, New York
| | - Megan Sutter
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Christina A Penfield
- Department of Obstetrics & Gynecology, New York University Langone Health,, New York, New York
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Matthews J, Soltis I, Villegas‐Downs M, Peters TA, Fink AM, Kim J, Zhou L, Romero L, McFarlin BL, Yeo W. Cloud-Integrated Smart Nanomembrane Wearables for Remote Wireless Continuous Health Monitoring of Postpartum Women. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2307609. [PMID: 38279514 PMCID: PMC10987106 DOI: 10.1002/advs.202307609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/15/2023] [Indexed: 01/28/2024]
Abstract
Noncommunicable diseases (NCD), such as obesity, diabetes, and cardiovascular disease, are defining healthcare challenges of the 21st century. Medical infrastructure, which for decades sought to reduce the incidence and severity of communicable diseases, has proven insufficient in meeting the intensive, long-term monitoring needs of many NCD disease patient groups. In addition, existing portable devices with rigid electronics are still limited in clinical use due to unreliable data, limited functionality, and lack of continuous measurement ability. Here, a wearable system for at-home cardiovascular monitoring of postpartum women-a group with urgently unmet NCD needs in the United States-using a cloud-integrated soft sternal device with conformal nanomembrane sensors is introduced. A supporting mobile application provides device data to a custom cloud architecture for real-time waveform analytics, including medical device-grade blood pressure prediction via deep learning, and shares the results with both patient and clinician to complete a robust and highly scalable remote monitoring ecosystem. Validated in a month-long clinical study with 20 postpartum Black women, the system demonstrates its ability to remotely monitor existing disease progression, stratify patient risk, and augment clinical decision-making by informing interventions for groups whose healthcare needs otherwise remain unmet in standard clinical practice.
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Affiliation(s)
- Jared Matthews
- IEN Center for Wearable Intelligent Systems and Healthcare at the Institute for Electronics and NanotechnologyGeorgia Institute of TechnologyAtlantaGA30332USA
- George W. Woodruff School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGA30332USA
| | - Ira Soltis
- IEN Center for Wearable Intelligent Systems and Healthcare at the Institute for Electronics and NanotechnologyGeorgia Institute of TechnologyAtlantaGA30332USA
- George W. Woodruff School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGA30332USA
| | - Michelle Villegas‐Downs
- Department of Human Development Nursing ScienceCollege of NursingUniversity of Illinois Chicago845 S. Damen Ave., MC 802ChicagoIL60612USA
| | - Tara A. Peters
- Department of Human Development Nursing ScienceCollege of NursingUniversity of Illinois Chicago845 S. Damen Ave., MC 802ChicagoIL60612USA
| | - Anne M. Fink
- Department of Biobehavioral Nursing ScienceCollege of NursingUniversity of Illinois Chicago845 S. Damen Ave., MC 802ChicagoIL60612USA
| | - Jihoon Kim
- IEN Center for Wearable Intelligent Systems and Healthcare at the Institute for Electronics and NanotechnologyGeorgia Institute of TechnologyAtlantaGA30332USA
- George W. Woodruff School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGA30332USA
| | - Lauren Zhou
- IEN Center for Wearable Intelligent Systems and Healthcare at the Institute for Electronics and NanotechnologyGeorgia Institute of TechnologyAtlantaGA30332USA
- George W. Woodruff School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGA30332USA
| | - Lissette Romero
- IEN Center for Wearable Intelligent Systems and Healthcare at the Institute for Electronics and NanotechnologyGeorgia Institute of TechnologyAtlantaGA30332USA
- George W. Woodruff School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGA30332USA
| | - Barbara L. McFarlin
- Department of Human Development Nursing ScienceCollege of NursingUniversity of Illinois Chicago845 S. Damen Ave., MC 802ChicagoIL60612USA
| | - Woon‐Hong Yeo
- IEN Center for Wearable Intelligent Systems and Healthcare at the Institute for Electronics and NanotechnologyGeorgia Institute of TechnologyAtlantaGA30332USA
- George W. Woodruff School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGA30332USA
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Tech and Emory University School of MedicineAtlantaGA30332USA
- Parker H. Petit Institute for Bioengineering and BiosciencesInstitute for MaterialsInstitute for Robotics and Intelligent MachinesGeorgia Institute of TechnologyAtlantaGA30332USA
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Francis B, Pearl M, Colen C, Shoben A, Sealy-Jefferson S. Racial and Economic Segregation Over the Life Course and Incident Hypertensive Disorders of Pregnancy Among Black Women in California. Am J Epidemiol 2024; 193:277-284. [PMID: 37771041 PMCID: PMC11031219 DOI: 10.1093/aje/kwad192] [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: 09/07/2022] [Revised: 07/24/2023] [Accepted: 09/26/2023] [Indexed: 09/30/2023] Open
Abstract
Black women in the United States have the highest incidence of hypertensive disorders of pregnancy (HDP) and are disproportionately burdened by its adverse sequalae, compared with women of all racial and ethnic groups. Segregation, a key driver of structural racism for Black families, can provide information critical to understanding these disparities. We examined the association between racial and economic segregation at 2 points and incident HDP using intergenerationally linked birth records of 45,204 Black California-born primiparous mothers (born 1982-1997) and their infants (born 1997-2011), with HDP ascertained from hospital discharge records. Women's early childhood and adulthood neighborhoods were categorized as deprived, mixed, or privileged based on the Index of Concentration at the Extremes (a measure of concentrated racial and economic segregation), yielding 9 life-course trajectories. Women living in deprived neighborhoods at both time points experienced the highest odds of HDP (from mixed effect logistic regression, unadjusted odds ratio = 1.26, 95% confidence interval: 1.13, 1.40) compared with women living in privileged neighborhoods at both time points. All trajectories involving residence in a deprived neighborhood in early childhood or adulthood were associated with increased odds of HDP, whereas mixed-privileged and privileged-mixed trajectories were not. Future studies should assess the causal nature of these associations.
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Affiliation(s)
- Brittney Francis
- Correspondence to Dr. Brittney Francis, 651 Huntington Avenue, Floor 7, Boston, MA 02115 (e-mail: )
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11
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Mitro SD, Hedderson M, Xu F, Forquer H, Baker JM, Kuzniewicz MW, Greenberg M. Risk of postpartum readmission after hypertensive disorder of pregnancy and variation by discharge antihypertensive medication prescription. Am J Obstet Gynecol 2024:S0002-9378(24)00046-2. [PMID: 38280432 PMCID: PMC11269521 DOI: 10.1016/j.ajog.2024.01.015] [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: 08/28/2023] [Revised: 01/12/2024] [Accepted: 01/22/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Patients with hypertensive disorders of pregnancy have a high rate of postpartum readmission. OBJECTIVE This study aimed to evaluate whether the type of antihypertensive medication prescribed at discharge was associated with postpartum readmission after a hypertensive disorder of pregnancy. STUDY DESIGN This was a retrospective cohort study of 57,254 pregnancies complicated by hypertensive disorders of pregnancy between 2012 and 2018 in the electronic obstetrical database of Kaiser Permanente Northern California. Postpartum readmissions occurred within 6 weeks after discharge from delivery hospitalization. Cox regression models were used to evaluate the association between the type of antihypertensive medication prescription at discharge (none, labetalol only, nifedipine only, or 2 or more antihypertensive medications) and postpartum readmission, adjusted for type of hypertensive disorder of pregnancy, final inpatient systolic and diastolic blood pressures, age, body mass index, mode of delivery, insurance status, race and ethnicity, delivery facility, comorbidity score, smoking, preterm delivery, parity, and Neighborhood Deprivation Index. RESULTS Among eligible patients with a hypertensive disorder of pregnancy, 1696 (3.0%) were readmitted within 6 weeks. Approximately 86% of patients were discharged without a prescription for antihypertensive medication; among those discharged with a prescription for antihypertensive medication, most were prescribed either labetalol only (54%) or nifedipine only (30%). The unadjusted readmission risk was the highest for patients discharged with a prescription for labetalol only (7.6%), lower for those discharged with a prescription for nifedipine only (3.6%) or 2 or more antihypertensive medications (3.2%), and the lowest for those discharged without a prescription for antihypertensive medication (2.5%). In the adjusted models, compared with discharge without a prescription for antihypertensive medication, discharge with a prescription for labetalol only was associated with a 63% (hazard ratio, 1.63; 95% confidence interval, 1.41-1.88) greater incidence of postpartum readmission, and discharge with a prescription for nifedipine only and discharge with a prescription for 2 or more antihypertensive medications were associated with 26% (hazard ratio, 0.74; 95% confidence interval, 0.59-0.93) and 47% (hazard ratio, 0.53; 95% confidence interval, 0.38-0.74) lower incidence of postpartum readmission, respectively. There was no strong evidence to suggest that the effect of the type of antihypertensive medication at discharge on the incidence of readmission varied by race and ethnicity (interaction P=.88). The results indicating an elevated risk associated with labetalol use were consistent in models that excluded patients with prepregnancy hypertension. CONCLUSION Discharge with a prescription for nifedipine alone or multiple antihypertensive medications (vs no medication) was associated with a lower incidence of readmission, whereas discharge with a prescription for labetalol alone was associated with an elevated readmission incidence. A large-scale, prospective research to compare the effectiveness of commonly prescribed hypertension medications at discharge is warranted.
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Affiliation(s)
- Susanna D Mitro
- Division of Research, Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland, CA.
| | - Monique Hedderson
- Division of Research, Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland, CA
| | - Fei Xu
- Division of Research, Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland, CA
| | - Heather Forquer
- Division of Research, Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland, CA
| | - Jennifer M Baker
- Division of Research, Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland, CA
| | - Michael W Kuzniewicz
- Division of Research, Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland, CA
| | - Mara Greenberg
- Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland, CA; Regional Perinatal Service Center, Kaiser Permanente Northern California, Santa Clara, CA
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McDougall HE, Yuan G, Olivier N, Tacey M, Langsford D. Multivariable risk model for postpartum re-presentation with hypertension: development phase. BMJ Open Qual 2023; 12:e002212. [PMID: 38154822 PMCID: PMC10759057 DOI: 10.1136/bmjoq-2022-002212] [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: 01/05/2023] [Accepted: 12/02/2023] [Indexed: 12/30/2023] Open
Abstract
OBJECTIVES Postpartum hypertension is one of the leading causes of re-presentation to hospital postpartum and is associated with adverse long-term cardiovascular risk. Postpartum blood pressure monitoring and management interventions have been shown to reduce hospital re-presentation, complications and long-term blood pressure control. Identifying patients at risk can be difficult as 40%-50% present with de novo postpartum hypertension. We aim to develop a risk model for postpartum re-presentation with hypertension using data readily available at the point of discharge. DESIGN A case-control study comparing all patients who re-presented to hospital with hypertension within 28 days post partum to a random sample of all deliveries who did not re-present with hypertension. Multivariable analysis identified risk factors and bootstrapping selected variables for inclusion in the model. The area under the receiver operator characteristic curve or C-statistic was used to test the model's discriminative ability. SETTING A retrospective review of all deliveries at a tertiary metropolitan hospital in Melbourne, Australia from 1 January 2016 to 30 December 2020. RESULTS There were 17 746 deliveries, 72 hypertension re-presentations of which 51.4% presented with de novo postpartum hypertension. 15 variables were considered for the multivariable model. We estimated a maximum of seven factors could be included to avoid overfitting. Bootstrapping selected six factors including pre-eclampsia, gestational hypertension, peak systolic blood pressure in the delivery admission, aspirin prescription and elective caesarean delivery with a C-statistic of 0.90 in a training cohort. CONCLUSION The development phase of this risk model builds on the three previously published models and uses factors readily available at the point of delivery admission discharge. Once tested in a validation cohort, this model could be used to identify at risk women for interventions to help prevent hypertension re-presentation and the short-term and long-term complications of postpartum hypertension.
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Affiliation(s)
| | - Grace Yuan
- Northern Health, Melbourne, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
| | | | - Mark Tacey
- Northern Health, Melbourne, Victoria, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - David Langsford
- The University of Melbourne, Parkville, Victoria, Australia
- Grampians Health, Ballarat, Victoria, Australia
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Dullabh P, Heaney-Huls KK, Chiao AB, Callaham MG, Desai P, Gauthreaux NA, Kashyap N, Lobach DF, Boxwala A. Implementation and evaluation of an electronic health record-integrated app for postpartum monitoring of hypertensive disorders of pregnancy using patient-contributed data collection. JAMIA Open 2023; 6:ooad098. [PMID: 38028731 PMCID: PMC10646567 DOI: 10.1093/jamiaopen/ooad098] [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: 02/28/2023] [Revised: 10/02/2023] [Accepted: 11/06/2023] [Indexed: 12/01/2023] Open
Abstract
Remote monitoring of women experiencing hypertensive disorders of pregnancy (HDP) can provide timely life-saving data, particularly if these data are integrated into existing patient and clinical workflows. This pilot intervention of a smartphone application (app) for postpartum monitoring of hypertensive disorders integrates patient-contributed data into electronic health records (EHRs) to support monitoring and clinical decision-making. Results from the evaluation of the pilot highlight the resources needed when implementing the app, challenges for integrating an app into the EHR, and the usability and utility of the HDP monitoring app for patient and clinician users. The implementation team's key observations included the importance of a local clinical champion, more robust patient involvement and support for the remote patient monitoring program, an impetus for EHR developers to adopt data integration standards, and a need to expand the capabilities of the standards to support interventions using patient-contributed data.
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Affiliation(s)
- Prashila Dullabh
- Health Sciences Department, NORC at the University of Chicago, Bethesda, MD 20814, United States
| | - Krysta K Heaney-Huls
- Health Sciences Department, NORC at the University of Chicago, Bethesda, MD 20814, United States
| | - Andrew B Chiao
- Health Sciences Department, NORC at the University of Chicago, Bethesda, MD 20814, United States
| | - Melissa G Callaham
- Health Sciences Department, NORC at the University of Chicago, Bethesda, MD 20814, United States
| | - Priyanka Desai
- Health Sciences Department, NORC at the University of Chicago, Bethesda, MD 20814, United States
| | - Nicole A Gauthreaux
- Health Sciences Department, NORC at the University of Chicago, Bethesda, MD 20814, United States
| | - Nitu Kashyap
- Department of Medicine,Yale New Haven Health, New Haven, CT 06510, United States
| | | | - Aziz Boxwala
- Elimu Informatics, El Cerrito, CA 94530, United States
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Ushida T, Nakamura N, Katsuki S, Mizutani H, Iitani Y, Imai K, Yoshida S, Yamashita M, Kajiyama H, Kotani T. New-onset postpartum hypertension in women without a history of hypertensive disorders of pregnancy: a multicenter study in Japan. Hypertens Res 2023; 46:2583-2592. [PMID: 37463981 DOI: 10.1038/s41440-023-01372-1] [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: 01/09/2023] [Revised: 05/10/2023] [Accepted: 06/19/2023] [Indexed: 07/20/2023]
Abstract
The aim of this study was to investigate the prevalence and risk factors of new-onset postpartum hypertension (PPHTN), defined as new-onset hypertension during the postpartum period, among women without a history of hypertension during pregnancy and labor. A multicenter retrospective study was conducted using clinical data of women who delivered at term between 2011 and 2018 at 12 maternity hospitals. A total of 18,295 normotensive women were eligible, after excluding those with hypertensive disorders of pregnancy or hypertension during labor. New-onset PPHTN was defined as multiple blood pressure readings of ≥ 140/90 mmHg between 1 d and 4 weeks postpartum among normotensive women throughout pregnancy. Multivariate regression analyses were performed to evaluate the risk factors for new-onset PPHTN. Among the 18,295 normotensive women, 227 (1.2%) presented with new-onset PPHTN. The prevalence was higher in women who delivered via cesarean section than in those who delivered vaginally (7.0% and 1.0%, respectively). The independent risk factors were maternal age ≥ 35 years (adjusted odds ratio 1.67, 95% confidence interval [1.10-2.53]), nulliparity (1.83 [1.24-2.71]), high normal blood pressure (systolic blood pressure [SBP] 120-129 and diastolic blood pressure [DBP] < 80) at the last prenatal check-up (1.96 [1.23-3.13]), elevated blood pressure (SBP 130-139 and/or DBP 80-89) (6.42 [4.15-9.95]), urinary protein 1+ (1.99 [1.27-3.11]), scheduled cesarean section (4.05 [1.69-9.69]), and emergency cesarean section (10.02 [5.10-19.70]). New-onset PPHTN was observed in 1.2% of the normotensive women, with women who delivered via cesarean section having the highest risk. Close postpartum blood pressure monitoring may be required for women with multiple risk factors to identify new-onset PPHTN in a timely manner and reduce adverse maternal consequences.
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Affiliation(s)
- Takafumi Ushida
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
- Division of Reproduction and Perinatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan.
| | - Noriyuki Nakamura
- Department of Obstetrics and Gynecology, Anjo Kosei Hospital, Aichi, Japan
| | - Satoru Katsuki
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidesuke Mizutani
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukako Iitani
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenji Imai
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | | | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomomi Kotani
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Division of Reproduction and Perinatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
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15
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Hamilton S, Olson S, Voegtline K, Lawson SM. Postpartum readmission in Maryland by race and ethnicity, 2016-2019. AJOG GLOBAL REPORTS 2023; 3:100278. [PMID: 38046531 PMCID: PMC10692712 DOI: 10.1016/j.xagr.2023.100278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND The majority of maternal deaths occur in the postpartum period. We sought to compare postpartum readmission by race and ethnicity to better understand whether there are disparities in maternal health in the postpartum period as indicated by readmission to the hospital. OBJECTIVE This study aimed to use state-wide Maryland data to identify postpartum readmission rates by race and ethnicity, as well as the major risk factors, indications, and timing of readmission. STUDY DESIGN In this retrospective study (2016-2019), childbirth hospitalizations for patients of childbearing age were identified from the Maryland State Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Indication for readmission was described. Multivariable logistic regression models were employed to determine racial and ethnic differences in postpartum readmissions, adjusting for maternal and obstetrical characteristics. RESULTS Among total deliveries (n=260,778), 3914 patients (1.5%) were readmitted within 60 days of delivery. The most common primary diagnoses at readmission were hypertension and infection. The prevalence of readmission was 1.2% (1306/111,325) for White patients, 2.3% (1786/79,412) for Black patients, 1.2% (485/40,862) for Hispanic patients and 1.2% (337/29,179) for patients of Other race or ethnicity (P<.0001). Black patients had the highest rates of readmission for hypertensive disorders as compared with all other races (37%, P<.0001). In adjusted models, Black patients were more likely to be readmitted than White patients (odds ratio, 1.64; confidence interval, 1.52-1.77). The majority of all readmissions occurred in the first week after delivery with Black patients having higher rates of readmission in the second week relative to all other groups (P<.0001). CONCLUSION Hypertension is a leading cause of postpartum readmission in Maryland. Black patients were more likely to be readmitted for hypertensive disorders of pregnancy and to have delayed readmission relative to other race or ethnic groups. Maryland public health officials should address disparities with interventions targeting racial and ethnic minorities, patients at risk for hypertensive disorders, and barriers to timely care.
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Affiliation(s)
- Sonia Hamilton
- Johns Hopkins University School of Medicine, Baltimore, MD (Ms Hamilton)
| | - Sarah Olson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (Ms Olson and Dr Voegtline)
| | - Kristin Voegtline
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (Ms Olson and Dr Voegtline)
| | - Shari M. Lawson
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Lawson)
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16
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Tallmadge M, Livergood MC, Tvina A, Evans S, McIntosh J, Palatnik A. Characteristics of Patients Who Attend the 7- to 10-Day Postpartum Visit for Blood Pressure Evaluation. Am J Perinatol 2023; 40:1579-1584. [PMID: 34775586 DOI: 10.1055/s-0041-1739291] [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: 10/19/2022]
Abstract
OBJECTIVE This study aimed to assess maternal characteristics that predict attendance of postpartum blood pressure evaluation in patients with hypertensive disorders of pregnancy (HDP). STUDY DESIGN A retrospective case-control study of patients with HDP delivering at a single academic institution (2014-2018). Diagnosis of HDP included gestational hypertension, chronic hypertension, preeclampsia, and superimposed preeclampsia. Univariable and multivariable analyses were used to determine maternal characteristics independently associated with attendance of the 7- to 10-day postpartum blood pressure evaluation. RESULTS Of the 1,041 patients included in the analysis, 603 (57.9%) attended the 7- to 10-day postpartum blood pressure check. Maternal sociodemographic, clinical, and obstetric factors differed significantly between patients who attended the postpartum blood pressure visit and those who did not. In univariable analyses, nulliparity, non-Hispanic black race and ethnicity, public insurance, HDP with severe features, cesarean birth, gestational age at delivery, receipt of magnesium, mild-range blood pressures on day of discharge, and initiation of antihypertensive medication were associated with attendance of the 7- to 10-day postpartum visit. In multivariable analysis, factors significantly associated with higher odds of attending the blood pressure visit were nulliparity (adjusted odds ratio [aOR]: 1.58; 95% confidence interval: [CI]: 1.14-2.17), severe HDP (aOR: 1.94, 95% CI: 1.44-2.61), and cesarean birth (aOR: 1.92, 95% CI: 1.43-2.59). In contrast, factors associated with lower odds of attendance were non-Hispanic black race and ethnicity compared with non-Hispanic white (aOR: 0.68, 95% CI: 0.47-0.97), and public insurance (aOR: 0.65, 95% CI: 0.45-0.93) compared with private insurance. CONCLUSION Clinical factors such as nulliparity, severe HDP, and cesarean birth were associated with higher rates of postpartum blood pressure evaluation attendance, whereas sociodemographic factors such as maternal non-Hispanic black race and ethnicity and public insurance were associated with lower odds of postpartum blood pressure check attendance. KEY POINTS · A total of 57.9% of patients with HDP attended in person postpartum blood pressure check.. · Nulliparity, severe features of HDP, and cesarean birth were associated with higher rates of attendance.. · Non-Hispanic black race and ethnicity and public insurance were associated with lower attendance..
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Affiliation(s)
- Maggie Tallmadge
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Alina Tvina
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sarah Evans
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer McIntosh
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin
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17
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Arkerson BJ, Finneran MM, Harris SR, Schnorr J, McElwee ER, Demosthenes L, Sawyer R. Remote Monitoring Compared With In-Office Surveillance of Blood Pressure in Patients With Pregnancy-Related Hypertension: A Randomized Controlled Trial. Obstet Gynecol 2023; 142:855-861. [PMID: 37734091 PMCID: PMC10510790 DOI: 10.1097/aog.0000000000005327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/30/2023] [Accepted: 04/06/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To compare the rate of blood pressure ascertainment within 10 days of postpartum discharge among individuals with hypertensive disorders of pregnancy randomized either to in-office blood pressure assessment or at-home monitoring. METHODS This was a multisite randomized controlled trial of postpartum patients diagnosed with a hypertensive disorder of pregnancy before discharge between April 2021 and September 2021 and was performed at two academic training institutions. Patients were randomized to either an in-office blood pressure check or remote monitoring through a web-enabled smartphone platform. The primary outcome was the rate of any blood pressure ascertainment within 10 days of discharge. Secondary outcomes include rates of initiation of antihypertensive medication, readmission, and additional office or triage visits for hypertension. Assuming a 10-day postdischarge blood pressure ascertainment rate of 50% in the in-office arm, we estimated that 186 participants would provide 80% power to detect a 20% difference in the primary outcome between groups. RESULTS One hundred ninety-seven patients were randomized (96 remote, 101 in-office). Patients with remote monitoring had higher rates of postpartum blood pressure ascertainment compared with in-office surveillance (91.7% [n=88] vs 58.4% [n=59]; P<.001). There were 11 (11.5%) patients in the intervention arm whose only qualifying blood pressure was a postdischarge in-person ascertainment, yielding a true remote monitoring uptake rate of 80.2%. In those with remote blood pressure uptake (n=77), the median number of blood pressure checks was 15 (interquartile range 6-26) and the median duration of remote monitoring use was 14 days (interquartile range 9-16). There were no differences in rates of readmission for hypertension (5.0% [n=5] vs 4.2% [n=4], P=.792) or initiation of antihypertensive medications after discharge (9.4% [n=9] vs 6.9% [n=7], P=.530). Rates of unscheduled visits were increased in the remote monitoring arm, but this did not reach statistical significance (5.0% [n=5] vs 12.5% [n=12], P=.059). When stratifying the primary outcome by race and randomization group, Black patients had lower rates of blood pressure ascertainment than White patients when assigned to in-office surveillance (41.2% [n=14] vs 69.5% [n=41], P=.007), but there was no difference in the remote management group (92.9% [n=26] vs 92.9% [n=52], P>.99). CONCLUSION Remote monitoring can increase postpartum blood pressure ascertainment within 10 days of discharge for women with hypertensive disorders of pregnancy and has the potential to promote health equity. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04823949.
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Affiliation(s)
- Brittany J Arkerson
- Departments of Obstetrics and Gynecology, Prisma Health-Upstate, Greenville, South Carolina, and the Medical University of South Carolina, Charleston, South Carolina
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18
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Sara A, Hunker DF. An Initiative to Increase Nurse Knowledge and Decrease Postpartum Readmissions for Preeclampsia. Nurs Womens Health 2023; 27:337-343. [PMID: 37572696 DOI: 10.1016/j.nwh.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/20/2023] [Accepted: 07/12/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVE To increase nurses' knowledge using innovative education and to improve maternal outcomes by reducing postpartum readmission rates of women with preeclampsia. DESIGN Quality improvement project implementing escape room-style education for nurses. SETTING/LOCAL PROBLEM A large tertiary hospital in southeastern Michigan with initial postpartum readmission rates of women with preeclampsia exceeding national averages. PARTICIPANTS Registered nurses (n = 71) working on the hospital postpartum unit; 70 completed the project. INTERVENTION/MEASUREMENTS Participants completed a knowledge survey on the care and management of women in the postpartum period with preeclampsia and then engaged in an escape room game scenario involving an increasingly acute case of a woman with preeclampsia. Debriefing occurred after the education, and then participants completed the same survey. Using data collected after the project, we compared postpartum readmission rates of women with preeclampsia to the median national average of 3.55%. RESULTS Nurse knowledge increased by 10.5% from the pre- to posttest period. For the 2-month project time period, the average readmission rate was 1.49%. CONCLUSION Offering innovative, interactive education to nurses, such as an escape room game, appeared to be an effective method to increase nurses' knowledge and may have improved maternal outcomes, as demonstrated through a readmission rate lower than the median national average. Further projects using longer time periods are needed to understand the true impact of the education on readmission rates.
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19
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Brown CC, Kuhn S, Stringfellow K, Moore JE, Ayers B. Association Between Mental Health Conditions at the Hospitalization for Birth and Postpartum Hospital Readmission. J Womens Health (Larchmt) 2023; 32:982-991. [PMID: 37327368 PMCID: PMC10517316 DOI: 10.1089/jwh.2022.0481] [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: 06/18/2023] Open
Abstract
Background: The relationship between physical comorbidities and postpartum hospital readmission is well studied, with less research regarding the impact of mental health conditions on postpartum readmission. Methods: Using hospital discharge data (2016-2019) from the Hospital Cost and Utilization Project Nationwide Readmissions Database (n = 12,222,654 weighted), we evaluated the impact of mental health conditions (0, 1, 2, and ≥3), as well as five individual conditions (anxiety, depressive, bipolar, schizophrenic, and traumatic/stress-related conditions) on readmission within 42 days, 1-7 days ("early"), and 8-42 days ("late") of hospitalization for birth. Results: In adjusted analyses, the rate of 42-day readmission was 2.2 times higher for individuals with ≥3 mental health conditions compared to those with none (3.38% vs. 1.56%; p < 0.001), 50% higher among individuals with 2 mental health conditions (2.33%; p < 0.001), and 40% higher among individuals with 1 mental health condition (2.17%; p < 0.001). We found increased adjusted risk of 42-day readmission for individuals with anxiety (1.98% vs. 1.59%; p < 0.001), bipolar (2.38% vs. 1.60%; p < 0.001), depressive (1.93% vs. 1.60%; p < 0.001), schizophrenic (4.00% vs. 1.61%; p < 0.001), and traumatic/stress-related conditions (2.21% vs. 1.61%; p < 0.001), relative to individuals without the respective condition. Mental health conditions had larger impacts on late (8-42 day) relative to early (1-7 day) readmission. Conclusions: This study found strong relationships between mental health conditions during the hospitalization for birth and readmission within 42 days. Efforts to reduce the high rates of adverse perinatal outcomes in the United States should continue to address the impact of mental health conditions during pregnancy and throughout the postpartum period.
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Affiliation(s)
- Clare C. Brown
- Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Savana Kuhn
- Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kristen Stringfellow
- Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jennifer E. Moore
- Institute for Medicaid Innovation, Washington, District of Columbia, USA
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Britni Ayers
- College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, Arkansas, USA
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Fant M, Rhoads S, Tucker J. Recognizing Early Warning Signs of Acute Hypertensive Crisis of the Postpartum Mother: An Important Role for Neonatal Nurses. Neonatal Netw 2023; 42:284-290. [PMID: 37657805 DOI: 10.1891/nn-2022-0060] [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] [Accepted: 05/08/2023] [Indexed: 09/03/2023]
Abstract
A delay in detecting acute hypertensive crisis in postpartum mothers can exacerbate complications in the mother. Neonatal nurses are uniquely qualified to identify postpartum warning signs in mothers while they are in the NICU with their infants. Few research studies have explored the use of neonatal nurse screenings for acute hypertensive crisis in postpartum mothers. NICU nurses screening mothers for postpartum depression has yielded success in improving outcomes, and this model could be translated into screening for acute hypertensive crisis. Further education should be implemented for NICU nurses that include a review of adult blood pressure monitoring, early warning signs, and symptoms of preeclampsia that the mother should report. This article discusses the importance of the neonatal nurse's role in identifying early warning signs of maternal postpartum hypertensive crisis.
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Corlin T, Raghuraman N, Rampersad RM, Sabol BA. Postpartum remote home blood pressure monitoring: the new frontier. AJOG GLOBAL REPORTS 2023; 3:100251. [PMID: 37560010 PMCID: PMC10407242 DOI: 10.1016/j.xagr.2023.100251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Abstract
There has been an alarming and substantial increase in hypertensive disorders of pregnancy, which are a significant driver of maternal morbidity and mortality. The postpartum period is an especially high-risk time, with >50% of pregnancy-related deaths and significant morbidity occurring during this period. The American College of Obstetricians and Gynecologists suggests inpatient or equivalent monitoring of blood pressures in patients with hypertensive disorders of pregnancy for the immediate 72 hours postpartum and again within 7 to 10 days postpartum. Hypertensive disorders of pregnancy significantly contribute to healthcare costs through increasing admission lengths, rates of readmissions, the number of medications given, and laboratory studies ordered, and through the immeasurable impact on the patient and society. Telemedicine is an essential option for patients with barriers to accessing care, particularly those in remote areas with difficulty accessing subspecialty care, transportation, childcare, or job security. The implementation of these programs also has potential to mitigate racial inequities given that patients of color are disproportionately affected by the morbidity and mortality of hypertensive disorders of pregnancy. Remote blood pressure monitoring programs are generally acceptable, with high levels of satisfaction in the obstetrical population without posing an undue burden of care. Studies have reported different, but encouraging, measures of feasibility, including rates of recruitment, consent, engagement, adherence, and retention in their programs. Considering these factors, the widespread adoption of postpartum blood pressure monitoring programs holds promise to improve the identification and care of this at-risk population. These immediate clinical effects are significant and can reduce short-term hypertension-related morbidity and even mortality, with the potential for long-term benefit with culturally competent, well-reimbursed, and widespread use of these programs. This clinical opinion aims to show that remote monitoring of postpartum hypertensive disorders of pregnancy is a reliable and effective alternative to current follow-up care models that achieves improved blood pressure control and diminishes racial disparities in care while simultaneously being acceptable to providers and patients and cost-saving to hospital systems.
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Affiliation(s)
- Tiffany Corlin
- Department of Obstetrics, Gynecology, and Women's Health, University of Minnesota, Minneapolis, MN (Drs Corlin and Sabol)
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO (Drs Raghuraman and Rampersad)
| | - Roxane M. Rampersad
- Department of Obstetrics and Gynecology, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO (Drs Raghuraman and Rampersad)
| | - Bethany A. Sabol
- Department of Obstetrics, Gynecology, and Women's Health, University of Minnesota, Minneapolis, MN (Drs Corlin and Sabol)
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Mei JY, Corry-Saavedra K, Nguyen TA, Murphy A. Standardized Clinical Assessment and Management Plan to Reduce Readmissions for Postpartum Hypertension. Obstet Gynecol 2023:00006250-990000000-00806. [PMID: 37411026 DOI: 10.1097/aog.0000000000005248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/20/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To evaluate the effect of a postpartum hypertension standardized clinical assessment and management plan on postpartum readmissions and emergency department (ED) visits. METHODS We conducted a prospective cohort study of patients with postpartum hypertension (either chronic hypertension or hypertensive disorders of pregnancy) who delivered at a single tertiary care center for 6 months after enacting an institution-wide standardized clinical assessment and management plan (postintervention group). Patients in the postintervention group were compared with patients in a historical control group. The standardized clinical assessment and management plan included 1) initiation or uptitration of medication for any blood pressure (BP) higher than 150/100 mm Hg or any two BPs higher than 140/90 mm Hg within a 24-hour period, with the goal of achieving normotension (BP lower than 140/90 mm Hg) in the 12 hours before discharge; and 2) enrollment in a remote BP monitoring system on discharge. The primary outcome was postpartum readmission or ED visit for hypertension. Multivariable logistic regression was used to evaluate the association between standardized clinical assessment and management plan and the selected outcomes. A sensitivity analysis was performed with propensity score weighting. A planned subanalysis in the postintervention cohort identified risk factors associated with requiring antihypertensive uptitration after discharge. For all analyses, the level of statistical significance was set at P<.05. RESULTS Overall, 390 patients in the postintervention cohort were compared with 390 patients in a historical control group. Baseline demographics were similar between groups with the exception of lower prevalence of chronic hypertension in the postintervention cohort (23.1% vs 32.1%, P=.005). The primary outcome occurred in 2.8% of patients in the postintervention group and in 11.0% of patients in the historical control group (adjusted odds ratio [aOR] 0.24, 95% CI 0.12-0.49, P<.001). A matched propensity score analysis controlling for chronic hypertension similarly demonstrated a significant reduction in the incidence of the primary outcome. Of the 255 patients (65.4%) who were compliant with outpatient remote BP monitoring, 53 (20.8%) had medication adjustments made per protocol at a median of 6 days (interquartile range 5-8 days) from delivery. Non-Hispanic Black race (aOR 3.42, 95% CI 1.68-6.97), chronic hypertension (aOR 2.09, 95% CI 1.13-3.89), having private insurance (aOR 3.04, 95% CI 1.06-8.72), and discharge on antihypertensive medications (aOR 2.39, 95% CI 1.33-4.30) were associated with requiring outpatient adjustments. CONCLUSION A standardized clinical assessment and management plan significantly reduced postpartum readmissions and ED visits for patients with hypertension. Close outpatient follow-up to ensure appropriate medication titration after discharge may be especially important in groups at high risk for readmission.
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Affiliation(s)
- Jenny Y Mei
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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Li J, Zhou Q, Wang Y, Duan L, Xu G, Zhu L, Zhou L, Peng L, Tang L, Yu Y. Risk factors associated with attendance at postpartum blood pressure follow-up visit in discharged patients with hypertensive disorders of pregnancy. BMC Pregnancy Childbirth 2023; 23:485. [PMID: 37391694 DOI: 10.1186/s12884-023-05780-6] [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: 12/14/2022] [Accepted: 06/12/2023] [Indexed: 07/02/2023] Open
Abstract
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.
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Affiliation(s)
- Jingjing Li
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Jiangsu Suzhou, 215002, China
| | - Qin Zhou
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Jiangsu Suzhou, 215002, China
| | - Yixuan Wang
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Jiangsu Suzhou, 215002, China
| | - Lufen Duan
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Jiangsu Suzhou, 215002, China
| | - Guangjuan Xu
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Jiangsu Suzhou, 215002, China
| | - Liping Zhu
- Department of Obstetrics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Jiangsu Suzhou, 215002, China
| | - Liping Zhou
- Department of Obstetrics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Jiangsu Suzhou, 215002, China
| | - Lan Peng
- Department of Obstetrics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Jiangsu Suzhou, 215002, China.
| | - Lian Tang
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Jiangsu Suzhou, 215002, China.
| | - Yanxia Yu
- Office of Clinical Trial Institutions, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Jiangsu Suzhou, 215002, China.
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Pfeiffer M, Gelsinger C, Palmsten K, Lipkind HS, Ackerman-Banks C, Ahrens KA. Rural-urban residence and sequelae of hypertensive disorders of pregnancy in the first year postpartum, 2007 - 2019. Pregnancy Hypertens 2023; 32:10-17. [PMID: 36822069 PMCID: PMC10219842 DOI: 10.1016/j.preghy.2023.02.002] [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: 06/02/2022] [Revised: 01/21/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVES To estimate the association between rural residence and sequelae of hypertensive disorders of pregnancy (HDP) in the first year postpartum. STUDY DESIGN We used the Maine Health Data Organization's All Payer Claims Data to identify women with HDP who delivered during 2007-2019 and did not have chronic hypertension or pre-pregnancy cardiac conditions (n = 8882). We used Cox proportional hazards modeling to estimate rural-urban hazard ratios (HR) and 95% confidence intervals (CI), adjusting for HDP subtype, age, insurance, nulliparity, and co-morbidities. Results were stratified by HDP subtype and timing of acute care visits. MAIN OUTCOME MEASURES Risk of at least one emergency room or inpatient visit related to hypertension or cardiovascular conditions in the first year postpartum and receipt of outpatient antihypertensive medications from 4 days to 1 year postpartum, separately. RESULTS Overall, risk of at least one acute care visit in the first year postpartum was not different between rural vs urban women (4.2% vs 4.2%; adjusted HR 0.98; 95% CI 0.79,1.21), and outpatient receipt of antihypertensive medication was not different (12.9% vs 12.8%; adjusted HR 0.99; 95% CI 0.87, 1.12). However, stratified analyses suggested some differences (e.g. preeclampsia with severe features: acute care visit adjusted HR 1.54; 95% CI 0.95, 2.49). CONCLUSIONS Rural and urban women do not differ in the risks of these common HDP sequelae, though rural women may have increased risk by HDP subtype or timing of acute care visit. Future research should investigate postpartum interventions for reducing HDP sequelae in rural and urban women.
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Affiliation(s)
- Mariah Pfeiffer
- Muskie School of Public Service, University of Southern Maine, Portland, ME, United States
| | - Catherine Gelsinger
- Muskie School of Public Service, University of Southern Maine, Portland, ME, United States
| | - Kristin Palmsten
- Pregnancy and Child Health Research Center, HealthPartners Institute, Minneapolis, MN, United States
| | - Heather S Lipkind
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, United States
| | | | - Katherine A Ahrens
- Muskie School of Public Service, University of Southern Maine, Portland, ME, United States.
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25
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Hayden-Robinson KA, Deeb JL. Postpartum Home Blood Pressure Monitoring Program: Improving Care for Hypertension During Postpartum after a Hospital Birth. MCN Am J Matern Child Nurs 2023; 48:134-141. [PMID: 36744869 DOI: 10.1097/nmc.0000000000000908] [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 AND SIGNIFICANCE Hypertensive disorders of pregnancy complicate about 10% of pregnancies and are a leading cause of maternal morbidity and mortality. PURPOSE The purpose of this quality improvement project was to evaluate a program to provide a home blood pressure monitor to all postpartum patients who had a hypertensive diagnosis and elevated blood pressure. METHODS The program includes a blood pressure monitor, instructions for its use, education about hypertension, and a guidance grid with standardized blood pressure parameters reviewed prior to discharge from the hospital. Patients are taught about potential adverse outcomes during postpartum. Patients are instructed to follow-up with their care provider based on the parameters. A retrospective medical record review was used to evaluate clinical outcomes. RESULTS Medical records of 185 patients indicated that 20% ( n = 36) who received the home BP monitor reported one or more mild-to-severe range blood pressure(s) during postpartum. Twenty-eight percent ( n = 52) had outpatient medication adjustments, including decreasing, increasing, starting, and discontinuing medications. Nine percent ( n = 17) of patients returned to the obstetric triage for evaluation. There was patient overlap between those experiencing elevated blood pressures, medication adjustments, and those who returned to hospital for evaluation. CLINICAL IMPLICATIONS Ongoing monitoring may improve identification and management of postpartum hypertension and potentially prevent progression to hypertensive-related adverse events.
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Palatnik A, Mukhtarova N, Hetzel SJ, Hoppe KK. Blood pressure changes in gestational hypertension, preeclampsia, and chronic hypertension from preconception to 42-day postpartum. Pregnancy Hypertens 2023; 31:25-31. [PMID: 36512857 DOI: 10.1016/j.preghy.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 10/20/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate blood pressure changes from preconception to 42-day postpartum in patients with gestational hypertension, preeclampsia, and chronic hypertension. STUDY DESIGN Secondary analysis of patients diagnosed with a hypertensive disorder of pregnancy (HDP) antenatally or postpartum, who were enrolled prospectively in a postpartum remote blood pressure (BP) monitoring program between March 2017 and May 2020. BP were collected at 47 time points: preconception, each trimester, delivery day, and every postpartum day through 42-days postpartum. The primary outcome of the study was to examine changes in BP over time and between the types of HDP for 42 days postpartum. Secondary outcomes included the difference in timing of BP stabilization (BPs < 140/90 mmHg for ≥ 48 h), BP resolution (stabilized without antihypertensive medication use), and antihypertensive medication usage at 42-day postpartum between the HDP groups. RESULTS A total of 1,194 patients were included in the cohort; 224 (18.8 %) had chronic hypertension (CHTN), 525 (43.9 %) had gestational hypertension (GHTN), 153 (12.8 %) had preeclampsia, and 292 (24.5 %) had preeclampsia with severe features. Postpartum BP peaked on days 5-7 postpartum with rapid decrease from postpartum day 7 until postpartum day 14, followed by very small resolution/stabilization in BP values between day 15 and 42 postpartum. By 6 weeks postpartum, 60.5 % of patients with CHTN still required antihypertensive medications to maintain BP < 140/90 mmHg. In the group of patients with preeclampsia with severe features, 32.6 % still required antihypertensive medications to maintain BP < 140/90 mmHg. Finally, 16.1 % patients with GHTN and 23.8 % of patients with preeclampsia without severe features required antihypertensive use at 6 weeks postpartum. The groups of CHTN and GHTN had significant reduction in SBPs at 42-days postpartum compared to their pre-conception BP (p < 0.001 for both groups). While diastolic BP at 42-days postpartum were not different in CHTN, GHTN and preeclampsia groups, compared to preconception, women with preeclampsia with severe features had higher diastolic BP at the end of 6-weeks postpartum period compared to preconception readings (p = 0.007). CONCLUSION Our study adds new information by examining BP trajectories through 42 days postpartum and demonstrates that all types of HDP are at risk of BP spikes and intervention through 42 days postpartum. We found that patients with CHTN had slower stabilization and resolution of their BP compared to patients with GHTN and preeclampsia with and without severe features. In addition, even at 42 days postpartum, a substantial proportion of patients with HDP, including GHTN, required antihypertensive treatment to maintain BP within stage I hypertension.
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Affiliation(s)
- Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Narmin Mukhtarova
- Department of Obstetrics & Gynecology, School of Medicine and Public Health, University of Wisconsin - Madison, Madison, WI, USA
| | - Scott J Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin - Madison, Madison, WI, USA
| | - Kara K Hoppe
- Department of Obstetrics & Gynecology, School of Medicine and Public Health, University of Wisconsin - Madison, Madison, WI, USA
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Kumar NR, Grobman WA, Haas DM, Silver RM, Reddy UM, Simhan H, Wing DA, Mercer BM, Yee LM. Association of Social Determinants of Health and Clinical Factors with Postpartum Hospital Readmissions among Nulliparous Individuals. Am J Perinatol 2023; 40:348-355. [PMID: 36427510 DOI: 10.1055/s-0042-1758485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Prior data suggest that there are racial and ethnic disparities in postpartum readmission among individuals, especially among those with hypertensive disorders of pregnancy. Existing reports commonly lack granular information on social determinants of health. The objective of this study was to investigate factors associated with postpartum readmission for individuals and address whether such risk factors differed by whether an individual had an antecedent diagnosis of a hypertensive disorder of pregnancy (HDP). STUDY DESIGN This is a secondary analysis of a large, multicenter prospective cohort study of 10,038 nulliparous participants. The primary outcome of this analysis was postpartum readmission. A priori, participants were analyzed separately based on whether they had HDP. Participant characteristics previously associated with a greater risk of perinatal morbidity or readmission (including social determinants of health, preexisting and chronic comorbidities, and intrapartum characteristics) were compared with bivariable analyses and retained in multivariable models if p < 0.05. Social determinants of health evaluated in this analysis included insurance status, self-identified race and ethnicity (as a proxy for structural racism), income, marital status, primary language, and educational attainment. RESULTS Of 9,457 participants eligible for inclusion, 1.7% (n = 165) were readmitted following initial hospital discharge. A higher proportion of individuals with HDP were readmitted compared with individuals without HDP (3.4 vs 1.3%, p < 0.001). Among participants without HDP, the only factors associated with postpartum readmission were chorioamnionitis and cesarean delivery. Among participants with HDP, gestational diabetes and postpartum hemorrhage requiring transfusion were associated with postpartum readmission. While the number of postpartum readmissions included in our analysis was relatively small, social determinants of health that we examined were not associated with postpartum readmission for either group. CONCLUSION In this diverse cohort of nulliparous pregnant individuals, there was a higher frequency of postpartum readmission among participants with HDP. Preexisting comorbidity and intrapartum complications were associated with postpartum readmission among this population engaged in a longitudinal study. KEY POINTS · Non-HDP patients had higher odds of PPR with chorioamnionitis or cesarean.. · HDP patients had higher odds of PPR if they had GDM or PPH.. · Characterizing PPR may identify and highlight modifiable factors..
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Affiliation(s)
- Natasha R Kumar
- Department of Obstetrics and Gynecology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Connecticut
| | - Hyagriv Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Deborah A Wing
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Parker SE, Ajayi A, Yarrington CD. De Novo Postpartum Hypertension: Incidence and Risk Factors at a Safety-Net Hospital. Hypertension 2023; 80:279-287. [PMID: 36377603 DOI: 10.1161/hypertensionaha.122.19275] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Postpartum hypertension can be persistent, following a pregnancy complicated by hypertension, or new onset (de novo), following a normotensive pregnancy. The aim of this study is to estimate the incidence and identify risk factors for de novo postpartum hypertension (dn-PPHTN) among a diverse safety-net hospital population. METHODS We conducted a retrospective cohort study of 3925 deliveries from 2016 to 2018. All blood pressure (BP) measures during pregnancy through 12 months postpartum were extracted from medical records. Patients with chronic hypertension or hypertensive disorders of pregnancy were excluded. dn-PPHTN was defined as 2 separate BP readings with systolic BP ≥140 mm Hg and diastolic BP ≥90 mm Hg at least 48 hours after delivery. Severe dn-PPHTN was defined as systolic BP ≥160 and diastolic BP ≥110. We examined risk factors individually and in combination and timing of diagnosis. RESULTS Among the 2465 patients without a history of hypertension, 12.1% (n=298) developed dn-PPHTN; 17.1% of whom had severe dn-PPHTN (n=51). Compared to those without dn-PPHTN; cases were more likely to be ≥35 years, delivered via cesarean, or be current or former smokers. Patients with all of these characteristics had a 29% risk of developing dn-PPHTN, which was elevated among non-Hispanic Black patients (36%). Approximately 22% of cases were diagnosed after 6 weeks postpartum. CONCLUSIONS More than 1 in 10 patients with normotensive pregnancies experience dn-PPHTN in the year after delivery. Opportunities to monitor and manage patients at the highest risk of dn-PPHTN throughout the entire year postpartum could mitigate cardiovascular related maternal morbidity.
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Affiliation(s)
- Samantha E Parker
- Department of Epidemiology, Boston University School of Public Health, MA (S.E.P., A.A.)
| | - Ayodele Ajayi
- Department of Epidemiology, Boston University School of Public Health, MA (S.E.P., A.A.)
| | - Christina D Yarrington
- Department of Obstetrics and Gynecology, Boston University School of Medicine, MA (C.D.Y.)
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29
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Anderson K, Howard ED. Timely Recognition and Treatment of Hypertension in Pregnancy: Key to Preventing Severe Maternal Morbidity and Mortality. J Perinat Neonatal Nurs 2023; 37:5-7. [PMID: 36707740 DOI: 10.1097/jpn.0000000000000707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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30
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Sequential measurement of the neurosensory retina in hypertensive disorders of pregnancy: a model of microvascular injury in hypertensive emergency. J Hum Hypertens 2023; 37:28-35. [PMID: 34625659 PMCID: PMC9831929 DOI: 10.1038/s41371-021-00617-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 09/13/2021] [Accepted: 09/24/2021] [Indexed: 01/31/2023]
Abstract
Optical coherence tomography of the eye suggests the retina thins in normal pregnancy. Our objectives were to confirm and extend these observations to women with hypertensive disorders of pregnancy (HDP). Maternal demographics, clinical/laboratory findings and measurements of macular thickness were repeatedly collected at gestational ages <20 weeks, 20-weeks to delivery, at delivery and postpartum. The primary outcome was the change in macular thickness from non-pregnant dimensions in women with incident HDP compared to non-hypertensive pregnant controls. Secondary outcomes were the relationship(s) between mean arterial pressure (MAP) and macular response. Data show macular thicknesses diminished at <20 weeks gestation in each of 27 pregnancies ending in HDP (mean 3.94 µm; 95% CI 4.66, 3.21) and 11 controls (mean 3.92 µm; 5.05, 2.79; P < 0.001 versus non-pregnant dimensions in both; P = 0.983 HDP versus controls). This thinning response continued to delivery in all controls and in 7 women with HDP superimposed on chronic hypertension. Macular thinning was lost after 20 weeks gestation in the other 20 women with HDP. MAP at loss of macular thinning in women without prior hypertension (n = 12) was identical to MAP at enrollment. However, mean MAP subsequently rose 19 mmHg (15, 22) leading to de novo HDP in all 12 women. Loss of thinning leading to a rise in MAP was also observed in 8 of 15 women with HDP superimposed on chronic hypertension. We conclude the macula thins in most women in early pregnancy. Those who lose this early macular thinning response often develop blood pressure elevations leading to HDP.
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31
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Kumar NR, Eucalitto PF, Trawick E, Lancki N, Yee LM. Examining changes in clinical management and postpartum readmissions for hypertensive disorders of pregnancy over time. Pregnancy Hypertens 2022; 30:82-86. [PMID: 36067638 PMCID: PMC9712231 DOI: 10.1016/j.preghy.2022.08.010] [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: 01/16/2022] [Revised: 08/09/2022] [Accepted: 08/22/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In response to 2013 guidelines for hypertensive disorders of pregnancy (HDP), our study examined changes in antenatal management and postpartum readmission (PPR) over time. STUDY DESIGN This is a retrospective cohort study of individuals diagnosed antenatally with HDP who delivered at a tertiary care center from 2012 to 2017. MAIN OUTCOME MEASURES The primary outcome was postpartum readmission for HDP in 2012-2013 vs 2014-2017. Secondary outcomes included intravenous magnesium administration and prescription for oral (PO) antihypertensive medication during delivery admission. Multivariable logistic regression models assessed differences in outcomes over time, adjusted for age, race, and payer status, for HDP with and without severe features, defined by ACOG criteria. RESULTS Of 5,300 eligible individuals, 73.5 % had HDP without severe features and 26.5 % had severe features. The PPR frequency in this cohort was 1.1 % (N = 59). There was no difference in PPR for individuals with HDP without severe features (aOR 0.73; 95 % CI 0.28-1.88) or with severe features (aOR 1.30; 95 % CI 0.50-3.39) by epoch. Magnesium administration for HDP with severe features remained below 80 % over time. Magnesium administration for HDP without severe features and discharge prescriptions for PO medications for HDP with severe features were lower after 2013. Neither magnesium administration nor discharge prescriptions were associated with decreased odds of PPR. CONCLUSION Although there was no difference in PPR for HDP after 2013, there were changes in antenatal management of HDP, including decreased magnesium administration for individuals with HDP without severe features and PO medication for individuals with severe features.
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Affiliation(s)
- Natasha R Kumar
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.
| | - Patrick F Eucalitto
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Emma Trawick
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Nicola Lancki
- Biostatistics Collaboration Center, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago IL, United States
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Early postpartum readmissions: identifying risk factors at birth hospitalization. AJOG GLOBAL REPORTS 2022; 2:100094. [DOI: 10.1016/j.xagr.2022.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Postpartum Readmission for Hypertension After Discharge on Labetalol or Nifedipine. Obstet Gynecol 2022; 140:591-598. [PMID: 36075068 DOI: 10.1097/aog.0000000000004918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/23/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To assess whether readmission for hypertension by 6 weeks postpartum differed between patients discharged on nifedipine or labetalol. METHODS This cohort study included patients with delivery admissions from 2006 to 2017 who were discharged from the hospital on nifedipine or labetalol and were included in a large, national adjudicated claims database. We identified patients' discharge medication based on filled outpatient prescriptions. We compared rates of hospital readmission for hypertension between patients discharged postpartum on labetalol alone, nifedipine alone, or combined nifedipine and labetalol. Patients with chronic hypertension without superimposed preeclampsia were excluded. Comparisons based on medication were performed using logistic regression models with adjustment for prespecified confounders. Comparisons were also stratified by hypertensive disorder of pregnancy severity. RESULTS Among 1,582,335 patients overall, 14,112 (0.89%) were discharged postpartum on labetalol, 9,001 (0.57%) on nifedipine, and 1,364 (0.09%) on both medications. Postpartum readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine (641 patients vs 185 patients, 4.5% vs 2.1%, adjusted odds ratio [aOR] 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine for both mild (4.5% vs 2.7%, aOR 1.57, 95% CI 1.29-1.93) and severe hypertensive disorders of pregnancy (261 patients vs 72 patients, 5.7% vs 3.2%, aOR 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent on combined nifedipine and labetalol compared with nifedipine (3.1% vs 2.1%), but the odds were lower after confounder adjustment (aOR 0.80, 95% CI 0.64-0.99). CONCLUSION Postpartum discharge on labetalol was associated with increased risk of readmission for hypertension compared with discharge on nifedipine.
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Griffin MM, Black M, Deeb J, Penfield CA, Hoskins IA. Postpartum Readmissions for Hypertensive Disorders in Pregnancy During the COVID-19 Pandemic. AJOG GLOBAL REPORTS 2022; 2:100108. [PMID: 36164558 PMCID: PMC9493139 DOI: 10.1016/j.xagr.2022.100108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hypertensive disorders in pregnancy are one of the most common causes of readmission in the postpartum period. Because of the COVID-19 pandemic, early hospital discharge was encouraged for patients who were medically stable, because hospitalization rates among SARS-CoV-2–infected patients steadily increased in 2020. The impact of an early discharge policy on postpartum readmission rates among patients with hypertensive disorders in pregnancy is unknown. OBJECTIVE This study aimed to compare the postpartum readmission rates of patients with hypertensive disorders in pregnancy before and after implementation of an early discharge policy owing to the COVID-19 pandemic. STUDY DESIGN This was a quality improvement, retrospective cohort study of postpartum patients with antenatal hypertensive disorders in pregnancy who delivered and were readmitted because of hypertensive disorders in pregnancy at the New York University Langone Health medical center from March 1, 2019 to February 29, 2020 (control cohort) and from April 1, 2020 to March 31, 2021 (COVID-19 cohort). During the pandemic, our institution introduced an early discharge policy for all postpartum patients to be discharged no later than 2 days postpartum during the delivery admission if deemed medically appropriate. The reduction in postpartum length of stay was accompanied by the continuation of patient education, home blood pressure monitoring, and outpatient follow-up. The primary outcome was the comparison of the readmission rates for patients with postpartum hypertensive disorders in pregnancy. Data were analyzed using Fisher's Exact tests, chi-square tests, and Wilcoxon rank-sum tests with significance defined as P<.05. RESULTS There was no statistical difference in the readmission rates for patients with postpartum hypertensive disorders in pregnancy before vs after implementation of an early discharge policy (1.08% for the control cohort vs 0.59% for the COVID-19 cohort). The demographics in each group were similar, as were the median times to readmission (5.0 days; interquartile range, 4.0–6.0 days vs 6.0 days; interquartile range, 5.0–6.0 days; P=.13) and the median readmission length of stay (3.0 days; interquartile range, 2.0–4.0 days vs 3.0 days; interquartile range, 2.0–4.0 days; P=.45). There was 1 intensive care unit readmission in the COVID-19 cohort and none in the control cohort (P=.35). There were no severe maternal morbidities or maternal deaths. CONCLUSION These findings suggest that policies calling for a reduced postpartum length of stay, which includes patients with hypertensive disorders in pregnancy, can be implemented without impacting the hospital readmission rate for patients with hypertensive disorders in pregnancy. Continuation of patient education and outpatient surveillance during the pandemic was instrumental for the outpatient postpartum management of the study cohort. Further investigation into best practices to support early discharges is warranted.
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Affiliation(s)
- Myah M. Griffin
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health Medical Center, New York, NY
- Corresponding author: Myah M. Griffin, MD.
| | - Mara Black
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Jessica Deeb
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Christina A. Penfield
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Iffath A. Hoskins
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
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Glazer KB, Harrell T, Balbierz A, Howell EA. Postpartum Hospital Readmissions and Emergency Department Visits Among High-Risk, Medicaid-Insured Women in New York City. J Womens Health (Larchmt) 2022; 31:1305-1313. [PMID: 35100055 PMCID: PMC9639235 DOI: 10.1089/jwh.2021.0338] [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: 11/12/2022] Open
Abstract
Objectives: To describe the incidence of and characteristics associated with postpartum emergency department (ED) visits and hospital readmissions among high-risk, low-income, predominantly Black and Latina women in New York City (NYC). Methods: We conducted a secondary analysis of detailed survey and medical chart data from an intervention to improve timely postpartum visits among Medicaid-insured, high-risk women in NYC from 2015 to 2016. Among 380 women who completed surveys at baseline (bedside postpartum) and 3 weeks after delivery, we examined the incidence of having an ED visit or readmission within 3 weeks postpartum. We used logistic regression to examine unadjusted and adjusted associations between patient demographic, clinical, and psychosocial characteristics and the odds of postpartum hospital use. Results: In total, 12.8% (n = 48) of women reported an ED visit or readmission within 3 weeks postpartum. Unadjusted odds of postpartum hospital use were higher among women who self-identified as Black versus Latina, U.S. born versus foreign born, and English versus Spanish speaking. Clinical and psychosocial characteristics associated with increased unadjusted odds of postpartum hospital use included cesarean delivery, hypertensive disorders of pregnancy, and positive depression or anxiety screen, and we found preliminary evidence of decreased hospital use among women breastfeeding at three weeks postpartum. The odds of seeking postpartum hospital care remained roughly 2.5 times higher among women with hypertension or depression/anxiety in adjusted analyses. Conclusions: We identified characteristics associated with ED visits and hospital readmissions among a high-risk subset of postpartum women in NYC. These characteristics, including depressive symptoms and hypertension, suggest women who may benefit from additional postpartum support to prevent maternal complications and reduce health disparities.
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Affiliation(s)
- Kimberly B. Glazer
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Taylor Harrell
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy Balbierz
- Grossman School of Medicine, New York University, New York, New York, USA
| | - Elizabeth A. Howell
- Department of Obstetrics & Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Torosyan N, Aziz D, Quesada O. Long-term sequelae of adverse pregnancy outcomes. Maturitas 2022; 165:1-7. [DOI: 10.1016/j.maturitas.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/17/2022] [Accepted: 06/23/2022] [Indexed: 10/31/2022]
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Abstract
Hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, and eclampsia, are a worldwide health problem. Hypertensive disorders of pregnancy affect more than 10% of pregnancies and are associated with increased mortality and morbidity for both mother and fetus. Although patients' outcomes and family's experience will always be the primary concern regarding hypertensive complications during pregnancy, the economic aspect of this disease is also worth noting. Compared with normotensive pregnancies, those related with hypertension resulted in an excess increase in hospitalization and healthcare cost. Hence, the focus of this review is to analyze hypertensive disorders of pregnancy and to present practical tips with clear instructions for the clinical management of hypertensive disorders of pregnancy. This overview offers a detailed approach from the diagnosis to treatment and follow-up of a pregnant women with hypertension, evidence based, to support these instructions.
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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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Malhamé I, Raker CA, Hardy EJ, Spalding H, Bouvier BA, Hurlburt H, Vrees R, Daskalopoulou SS, Nerenberg K, Savitz DA, Mehta N, Danilack VA. Development and Internal Validation of a Risk Prediction Model for Acute Cardiovascular Morbidity in Preeclampsia. Can J Cardiol 2022; 38:1591-1599. [PMID: 35709932 DOI: 10.1016/j.cjca.2022.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/05/2022] [Accepted: 05/08/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Persons with preeclampsia are at increased short-term risk of adverse cardiovascular outcomes during pregnancy and the early postpartum period. We aimed to develop and internally validate a risk assessment tool to predict acute cardiovascular morbidity in preeclampsia. METHODS The study was conducted at an academic obstetric hospital. Participants with preeclampsia at delivery between 2007 and 2017 were included. A model to predict acute cardiovascular morbidity at delivery and within 6 weeks postpartum was developed and evaluated. The primary composite outcome included pulmonary edema/acute heart failure, myocardial infarction, aneurysm, cardiac arrest/ventricular fibrillation, heart failure/arrest during surgery or procedure, cerebrovascular disorders, cardiogenic shock, conversion of cardiac rhythm, and difficult-to-control severe hypertension. We assessed model discrimination and calibration. We used bootstrapping for internal validation. RESULTS 4,171 participants with preeclampsia were included. The final model comprised 8 variables. Predictors positively associated with acute cardiovascular morbidity (presented as odds ratio [OR] with 95% confidence interval [CI]) were: gestational age at delivery (20-36 weeks 5.36 [3.67, 7.82]; 37-38 weeks 1.75 [1.16, 2.64]), maternal age (≥40 years 1.65 [1.00, 2.72]; 35-39 years 1.49 [1.07, 2.09]), and prior cesarean delivery (1.47, [1.01, 2.13]). The model had an area under the receiver operating characteristic curve of 0.72 (95% CI [0.69, 0.74]). Moreover, it was adequately calibrated and performed well on internal validation. CONCLUSIONS This risk prediction tool identified women with preeclampsia at highest risk of acute cardiovascular morbidity. If externally validated, this tool may facilitate early interventions aimed at preventing adverse cardiovascular outcomes in pregnancy and postpartum.
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Affiliation(s)
- Isabelle Malhamé
- Department of Medicine, McGill University, McGill University Health Centre, Montreal, Quebec, Canada; Research institute of the McGill University Health Centre, Montreal, Quebec, Canada.
| | - Christina A Raker
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA
| | - Erica J Hardy
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA; Department of Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, USA
| | - Hannah Spalding
- Department of Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, USA
| | - Benjamin A Bouvier
- Department of Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, USA
| | - Heather Hurlburt
- Department of Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, USA
| | - Roxanne Vrees
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA
| | - Stella S Daskalopoulou
- Department of Medicine, McGill University, McGill University Health Centre, Montreal, Quebec, Canada; Research institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Kara Nerenberg
- Departments of Medicine, Obstetrics & Gynecology, and Community Health Sciences Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David A Savitz
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA; Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Niharika Mehta
- Department of Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Valery A Danilack
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA; Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
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Combs CA, Goffman D, Pettker CM, Pettker C. Society for Maternal-Fetal Medicine Special Statement: A critique of postpartum readmission rate as a quality metric. Am J Obstet Gynecol 2022; 226:B2-B9. [PMID: 34838802 DOI: 10.1016/j.ajog.2021.11.1355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Hospital readmission is considered a core measure of quality in healthcare. Readmission soon after hospital discharge can result from suboptimal care during the index hospitalization or from inadequate systems for postdischarge care. For many conditions, readmission is associated with a high rate of serious morbidity and potentially avoidable costs. In obstetrics, for postpartum care specifically, hospitals and payers can easily track the rate of maternal readmission after childbirth and may seek to incentivize obstetricians, maternal-fetal medicine specialists, or provider groups to reduce the rate of readmission. However, this practice has not been shown to improve outcomes or reduce harm. There are major concerns with incentivizing providers to reduce postpartum readmissions, including the lack of a standardized metric, a baseline rate of 1% to 2% that is too low to accurately discriminate between random variation and controllable factors, the need for risk adjustment that greatly complicates rate calculations, the potential for bias depending on the duration of the follow-up interval, the potential for the "gaming" of the metric, the lack of evidence that obstetrical providers can influence the rate, and the potential for unintended harm in the vulnerable postpartum population. Until these problems are adequately addressed, maternal readmission rate after a childbirth hospitalization currently has limited utility as a metric for quality or performance improvement or as a factor to adjust provider reimbursement.
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Sakai-Bizmark R, Kumamaru H, Estevez D, Neman S, Bedel LEM, Mena LA, Marr EH, Ross MG. Reduced rate of postpartum readmissions among homeless compared with non-homeless women in New York: a population-based study using serial, cross-sectional data. BMJ Qual Saf 2022; 31:267-277. [DOI: 10.1136/bmjqs-2020-012898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/27/2021] [Indexed: 01/04/2023]
Abstract
ObjectiveTo assess differences in rates of postpartum hospitalisations among homeless women compared with non-homeless women.DesignCross-sectional secondary analysis of readmissions and emergency department (ED) utilisation among postpartum women using hierarchical regression models adjusted for age, race/ethnicity, insurance type during delivery, delivery length of stay, maternal comorbidity index score, other pregnancy complications, neonatal complications, caesarean delivery, year fixed effect and a birth hospital random effect.SettingNew York statewide inpatient and emergency department databases (2009–2014).Participants82 820 and 1 026 965 postpartum homeless and non-homeless women, respectively.Main outcome measuresPostpartum readmissions (primary outcome) and postpartum ED visits (secondary outcome) within 6 weeks after discharge date from delivery hospitalisation.ResultsHomeless women had lower rates of both postpartum readmissions (risk-adjusted rates: 1.4% vs 1.6%; adjusted OR (aOR) 0.87, 95% CI 0.75 to 1.00, p=0.048) and ED visits than non-homeless women (risk-adjusted rates: 8.1% vs 9.5%; aOR 0.83, 95% CI 0.77 to 0.90, p<0.001). A sensitivity analysis stratifying the non-homeless population by income quartile revealed significantly lower hospitalisation rates of homeless women compared with housed women in the lowest income quartile. These results were surprising due to the trend of postpartum hospitalisation rates increasing as income levels decreased.ConclusionsTwo factors likely led to lower rates of hospital readmissions among homeless women. First, barriers including lack of transportation, payment or childcare could have impeded access to postpartum inpatient and emergency care. Second, given New York State’s extensive safety net, discharge planning such as respite and sober living housing may have provided access to outpatient care and quality of life, preventing adverse health events. Additional research using outpatient data and patient perspectives is needed to recognise how the factors affect postpartum health among homeless women. These findings could aid in lowering readmissions of the housed postpartum population.
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Christine Livergood M, Hauck J, Mahlum L, Tallmadge M, Russell R, Kulinski J, Palatnik A. Risk of unplanned healthcare utilization in postpartum period for patients with hypertensive disorders of pregnancy. Pregnancy Hypertens 2022; 27:189-192. [PMID: 35124426 DOI: 10.1016/j.preghy.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/31/2021] [Accepted: 01/29/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine which factors are associated with unplanned postpartum healthcare utilization, including hospital readmission and unplanned outpatient and emergency room visits, in patients with hypertensive disorders of pregnancy (HDP). STUDY DESIGN This was a case control study of patients with HDP delivering at a single academic institution from 2014 through 2018. The diagnosis of HDP included chronic hypertension, gestational hypertension, preeclampsia and superimposed preeclampsia. Using bivariate and multivariate analysis, demographic and clinical characteristics were compared between patients who had unplanned healthcare utilization, defined as readmission to the hospital, emergency room visit or unplanned outpatient encounter in the first 6-weeks postpartum, and those patients who did not. RESULTS Of the 1427 patients with HDP included in this analysis, 174 (12.2%) had unplanned postpartum healthcare utilization. Maternal non-Hispanic Black race and ethnicity and presence of mild blood pressures on the day of discharge after delivery were associated with higher odds of unplanned healthcare utilization (aOR 1.67, 95% CI 1.08 - 2.56 and aOR 1.59, 95% CI 1.12 - 2.27, respectively). In contrast, presence of chronic hypertension was associated with lower odds of unplanned postpartum healthcare utilization (aOR 0.47, 95% CI 0.28 - 0.79) CONCLUSION: Among postpartum patients with HDP, non-Hispanic Black race and ethnicity and discharge home with mild range blood pressures were associated with higher odds of unplanned healthcare utilization in the first 6 weeks postpartum, while chronic hypertension was associated with lower odds.
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Affiliation(s)
- M Christine Livergood
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jordan Hauck
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Leigh Mahlum
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Maggie Tallmadge
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Rachel Russell
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jacquelyn Kulinski
- Depatment of Medicine, Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, United States.
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Khosla K, Suresh S, Mueller A, Perdigao JL, Stewart K, Duncan C, Oladipo V, Fess E, Heimberger S, Rana S. Elimination of Racial Disparities in Postpartum Hypertension Follow-Up After Incorporation of Telehealth into a Quality Bundle. Am J Obstet Gynecol MFM 2022; 4:100580. [PMID: 35121193 DOI: 10.1016/j.ajogmf.2022.100580] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/28/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Black people have disproportionately higher risk for hypertensive disorders of pregnancy and postpartum complications than White people, but historically lower rates of postpartum follow-up. Few studies have investigated telehealth in the postpartum population. OBJECTIVES This study aimed to investigate whether rapid switch to telehealth during the COVID-19 pandemic decreased racial disparities in postpartum hypertension follow-up adherence. STUDY DESIGN This retrospective cohort study included all patients with hypertensive disorders of pregnancy who delivered between December 2019 and June 2020 at an urban, tertiary-care center. A preexisting, postpartum hypertension quality improvement initiative was in place at this institution. Follow-up adherence within six weeks postpartum and at the six-week visit were compared prior to February 15, 2020 (pre-telehealth period) and following March 14, 2020 (post-telehealth period), with a one-month implementation/washout period. Blood pressures at these visits were compared between time periods as a secondary outcome. RESULTS A total of 473 patients were included in this analysis, of whom 76.3% were Non-Hispanic (NH) Black. There were 215 and 258 patients in the pre- and post-telehealth cohorts, respectively. Among those who attended follow-up, the proportion of visits done over telehealth went from 0% pre-telehealth to 98.0% post-telehealth. The proportion of postpartum hypertension follow-up attendance changed from 48.5% to 76.3% among NH Black people (p<0.0001) and 73.1% to 76.7% among NH White people (p=0.76), leaving only a 0.4% racial gap (p = 0.97) resulting in an elimination of the racial disparity in the post-telehealth period. CONCLUSION Transition to telehealth with audio-based visits at the onset of the COVID-19 pandemic improved attendance at postpartum hypertension visits amongst NH Black people and therefore led to significant decreases in the racial disparity in follow-up rates at our institution in the setting of an existing quality improvement initiative. Further research should focus on the intentional use of telehealth in improving maternal outcomes especially among NH Black.
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Affiliation(s)
- Kavia Khosla
- Pritzker School of Medicine, The University of Chicago, Chicago, IL (Mses Khosla and Heimberger)
| | - Sunitha Suresh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL (Drs Suresh and Perdigao, Mses Duncan and Fess, and Dr Rana)
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Ms Mueller)
| | - Joana L Perdigao
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL (Drs Suresh and Perdigao, Mses Duncan and Fess, and Dr Rana)
| | - Karie Stewart
- Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL (Ms Stewart)
| | - Colleen Duncan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL (Drs Suresh and Perdigao, Mses Duncan and Fess, and Dr Rana)
| | | | - Emily Fess
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL (Drs Suresh and Perdigao, Mses Duncan and Fess, and Dr Rana)
| | - Sarah Heimberger
- Pritzker School of Medicine, The University of Chicago, Chicago, IL (Mses Khosla and Heimberger)
| | - Sarosh Rana
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL (Drs Suresh and Perdigao, Mses Duncan and Fess, and Dr Rana).
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Postpartum preeclampsia or eclampsia: defining its place and management among the hypertensive disorders of pregnancy. Am J Obstet Gynecol 2022; 226:S1211-S1221. [PMID: 35177218 PMCID: PMC8857508 DOI: 10.1016/j.ajog.2020.10.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/05/2020] [Accepted: 10/19/2020] [Indexed: 02/03/2023]
Abstract
High blood pressure in the postpartum period is most commonly seen in women with antenatal hypertensive disorders, but it can develop de novo in the postpartum time frame. Whether postpartum preeclampsia or eclampsia represents a separate entity from preeclampsia or eclampsia with antepartum onset is unclear. Although definitions vary, the diagnosis of postpartum preeclampsia should be considered in women with new-onset hypertension 48 hours to 6 weeks after delivery. New-onset postpartum preeclampsia is an understudied disease entity with few evidence-based guidelines to guide diagnosis and management. We propose that new-onset hypertension with the presence of any severe features (including severely elevated blood pressure in women with no history of hypertension) be referred to as postpartum preeclampsia after exclusion of other etiologies to facilitate recognition and timely management. Older maternal age, black race, maternal obesity, and cesarean delivery are all associated with a higher risk of postpartum preeclampsia. Most women with delayed-onset postpartum preeclampsia present within the first 7 to 10 days after delivery, most frequently with neurologic symptoms, typically headache. The cornerstones of treatment include the use of antihypertensive agents, magnesium, and diuresis. Postpartum preeclampsia may be associated with a higher risk of maternal morbidity than preeclampsia with antepartum onset, yet it remains an understudied disease process. Future research should focus on the pathophysiology and specific risk factors. A better understanding is imperative for patient care and counseling and anticipatory guidance before hospital discharge and is important for the reduction of maternal morbidity and mortality in the postpartum period.
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DeVries CR, Starbird WT, Arab A, Bailey B. Investigation of factors that predict risk for hospital readmission following delivery of pregnancies complicated by hypertensive disorders of pregnancy. J Matern Fetal Neonatal Med 2022; 35:9320-9324. [PMID: 35073822 DOI: 10.1080/14767058.2022.2030306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate specific risk factors and their impact on hospital readmission risk following delivery in pregnancies affected by the hypertensive disease of pregnancy (HDP). METHODS We performed a 10-year case-control study for patients who delivered at our institution and whose antenatal courses were complicated by HDP. The primary outcome was the identification of specific patient factors contributing to readmission. HDP pregnancies experiencing readmission for HDP signs and/or symptoms were used as the cases, with HDP pregnancies not experiencing readmission randomly selected as controls. Maternal age, gestational age at delivery, gravidity, parity, and mode of delivery (vaginal including operative, or cesarean) were recorded. Mean systolic and diastolic blood pressures were calculated over the 24 h preceding discharge. The most recent laboratory values preceding discharge for serum creatinine, lactate dehydrogenase, aspartate aminotransferase, alanine transaminase, and platelets were also recorded. The presence or absence of prescribed antihypertensive medication was recorded for initial hospitalization. Postpartum readmission was defined as within 30 days of delivery. Exclusion criteria involved readmission for non-HDP cause and maternal age less than 17 at delivery. RESULTS Within the study timeframe, 3601 patients with pregnancies complicated with HDP were identified. Of these, 34 patients were readmitted within 30 days postpartum for signs and/or symptoms of HDP after exclusion criteria were applied A cohort of 50 controls were used for comparison for a total of 84 participants. A diagnosis of pre-eclampsia was significantly associated with readmission (p=.004) when compared to other HDP diagnoses. Demonstration of severe disease features also was associated significantly (p < 0.001) with readmission. Parity greater than or equal to three also was associated with readmission (p = 0.019). Notably, age, BMI, delivery mode, blood pressure preceding discharge, length of hospital stay, and being discharged with antihypertensive medication were not significantly associated with readmission. CONCLUSION This study suggests that readmission overall for the hypertensive disease of pregnancy is rare, but that patient variables of increasing parity and presence of severe features were associated with postpartum readmission. Knowledge of these variables may assist physicians in the identification of HDP patients who are at higher risk for readmission.
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Affiliation(s)
- Christopher R DeVries
- D epartment of Obstetrics & Gynecology, Central Michigan University School of Medicine, Saginaw, MI, USA
| | | | - Aarthi Arab
- Central Michigan University School of Medicine, Saginaw, MI, USA
| | - Beth Bailey
- Central Michigan University, Mount Pleasant, MI, USA
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Matas JL, Mitchell LE, Sharma SV, Louis JM, Salemi JL. Severe maternal morbidity at delivery and postpartum readmission in the United States. Paediatr Perinat Epidemiol 2021; 35:627-634. [PMID: 33738822 DOI: 10.1111/ppe.12762] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/06/2021] [Accepted: 02/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about the extent to which severe maternal morbidity (SMM) at delivery impacts early and late postpartum readmission. OBJECTIVES We examined readmission rates for women with and without SMM (and their 18 subtypes) at delivery and characterised the most common medical reasons for readmissions. METHODS We conducted a retrospective cohort study utilising the 2016-2017 Nationwide Readmissions Database among women giving births in the United States. Deliveries were classified according to the presence or absence of 18 SMM indicators defined by the Centers for Disease Control and Prevention using the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) diagnosis and procedure codes. The primary outcome of this study was all-cause early (≤7 day) and late (8 to 42 day) postpartum readmission. Survey-weighted Poisson regression with robust error variance was used to generate adjusted risk ratios (RR) and 95% confidence intervals (CI) to investigate the association between SMM and early and late postpartum readmission. Additionally, we compared principal diagnoses codes during readmission hospitalisations among women with and without SMM at delivery. RESULTS Of the 6 193 852 women examined, 4.9% (n = 4928) with any SMM and 1.4% (n = 83 995) with no SMM were readmitted within 42 days after delivery. After adjusting for obstetric co-morbidities and sociodemographic factors, women with any SMM were 57% (RR 1.57, 95% CI 1.47, 1.67) more likely to have an early readmission and 69% (RR 1.69, 95% CI 1.57, 1.82) more likely to have a late readmission compared to women with no SMM at delivery. However, the risk was attenuated when excluding women with blood transfusion only. Women with and without SMM were readmitted predominantly for obstetric complications and infections. CONCLUSIONS Women with SMM at delivery were more likely to experience both early and late postpartum readmission, independent of their obstetrical co-morbidity burden and sociodemographic factors.
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Affiliation(s)
- Jennifer L Matas
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth, School of Public Health, Houston, TX, USA
| | - Laura E Mitchell
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth, School of Public Health, Houston, TX, USA
| | - Shreela V Sharma
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth, School of Public Health, Houston, TX, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jason L Salemi
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.,College of Public Health, University of South Florida, Tampa, FL, USA
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Chornock R, Iqbal SN, Kawakita T. Racial Disparity in Postpartum Readmission due to Hypertension among Women with Pregnancy-Associated Hypertension. Am J Perinatol 2021; 38:1297-1302. [PMID: 32485755 DOI: 10.1055/s-0040-1712530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Postpartum hypertension is a leading cause of readmission in the postpartum period. We aimed to examine the prevalence of racial/ethnic differences in postpartum readmission due to hypertension in women with antepartum pregnancy-associated hypertension. STUDY DESIGN This was a multi-institutional retrospective cohort study of all women with antepartum pregnancy-associated hypertension diagnosed prior to initial discharge from January 2009 to December 2016. Antepartum pregnancy-associated hypertension, such as gestational hypertension, preeclampsia (with or without severe features), hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome, and eclampsia was diagnosed based on American College of Obstetricians and Gynecologists Task Force definitions. Women with chronic hypertension and superimposed preeclampsia were excluded. Our primary outcome was postpartum readmission defined as a readmission due to severe hypertension within 6 weeks of postpartum. Risk factors including maternal age, gestational age at admission, insurance, race/ethnicity (self-reported), type of antepartum pregnancy-associated hypertension, marital status, body mass index (kg/m2), diabetes (gestational or pregestational), use of antihypertensive medications, mode of delivery, and postpartum day 1 systolic blood pressure levels were examined. Multivariable logistic regression models were performed to calculate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs). RESULTS Of 4,317 women with pregnancy-associated hypertension before initial discharge, 66 (1.5%) had postpartum readmission due to hypertension. Risk factors associated with postpartum readmission due to hypertension included older maternal age (aOR = 1.44; 95% CI: 1.20-1.73 for every 5 year increase) and non-Hispanic black race (aOR = 2.12; 95% CI: 1.16-3.87). CONCLUSION In women with pregnancy-associated hypertension before initial discharge, non-Hispanic black women were at increased odds of postpartum readmission due to hypertension compared with non-Hispanic white women.
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Affiliation(s)
- Rebecca Chornock
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Sara N Iqbal
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Tetsuya Kawakita
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia
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Niu B, Mukhtarova N, Alagoz O, Hoppe K. Cost-effectiveness of telehealth with remote patient monitoring for postpartum hypertension. J Matern Fetal Neonatal Med 2021; 35:7555-7561. [PMID: 34470135 DOI: 10.1080/14767058.2021.1956456] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Evaluate cost-effectiveness of telehealth with remote monitoring for postpartum hypertensive disorders from the hospital's perspective. METHODS A decision tree was developed using results from a non-randomized controlled trial comparing telehealth to standard outpatient blood pressure monitoring. At discharge, postpartum women with a hypertensive disorder received a Bluetooth tablet, blood pressure monitor, and scale to submit vitals daily for 6 weeks. Women were managed and treated with a standard protocol. We performed a cost-effectiveness analysis using data from the hospital, device manufacturer supplied charges, and utilities. A cost-effectiveness threshold was set at $100,000/quality-adjusted life years. One-way and two-way sensitivity analyses were performed to evaluate the robustness of our results compared to baseline assumptions. RESULTS Telehealth monitoring significantly reduced postpartum readmissions, 3.7% (8/214) versus 0.5% (1/214), and resulted in higher quality-adjusted life years. Telehealth monitoring was cost-effective and cost-saving. Average cost of telehealth per patient was $309, and was cost-effective to a cost of $420 per patient. Telehealth monitoring remained cost-effective down to an admission cost of $10,999 compared to our baseline-estimate for the average admission cost of $14,401. Telehealth monitoring also remained cost-effective when the postpartum readmission rate was 3.0% or higher with standard monitoring. With a cost saving of $93 per patient and an estimated 333,253 pregnant women with hypertension in the US a year, telehealth could reduce health care costs in the US by approximately $31 million a year. CONCLUSIONS This study demonstrates telehealth with remote blood pressure monitoring may be a cost-effective and cost-saving solution for management of postpartum hypertension.
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Affiliation(s)
- Brenda Niu
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Narmin Mukhtarova
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Oguzhan Alagoz
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.,Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA.,Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Kara Hoppe
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
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The Impact of Preeclampsia on Women's Health: Cardiovascular Long-term Implications. Obstet Gynecol Surv 2021; 75:703-709. [PMID: 33252700 DOI: 10.1097/ogx.0000000000000846] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Women with a history of preeclampsia have a 2- to 5-fold increased risk of cardiovascular diseases, which represent almost half of mortality in the female population worldwide. Objective To summarize the current evidence concerning women's future cardiovascular risk after pregnancies complicated by preeclampsia. Evidence Acquisition A PubMed and Web of Science search was conducted in English, supplemented by hand searching for additional references. Retrieved articles were reviewed, synthesized, and summarized. Relevant studies on cardiovascular risk after preeclampsia were included. Results Evidence suggests that the cardiovascular implications of preeclampsia do not cease with delivery, with a significant proportion of women demonstrating persistent asymptomatic myocardial impairment, aortic stiffening, and microcirculatory dysfunction. More severe and early-onset preeclampsia, as well as preeclampsia with concurrent neonatal morbidity, increases the risk of cardiovascular disease later in life. Conclusions and Relevance As former preeclamptics have been shown to be at increased cardiovascular risk, this identifies a subgroup of women who may benefit from early preventive measures.
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Gomez HB, Hoffman MK. Text Messaging as a Means to Engage Patients in the Postpartum Period. Clin Obstet Gynecol 2021; 64:366-374. [PMID: 33904842 DOI: 10.1097/grf.0000000000000609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The use of electronic information and telecommunications technologies to support health systems has been increasingly recognized as an important tool in postpartum care. An emerging body of research has suggested that telehealth during the postpartum period may alleviate racial disparities and transportation barriers, while improving access to health resources. Thus, the purpose of this article is to describe current barriers to postpartum health, review prevalence and access to mobile devices, and current uses of text messaging in the postpartum period. We describe key areas of telemedicine utilization including lactation services, blood pressure monitoring, diabetes screening, mental health services, weight loss programs, and access to contraception in the postpartum period. Future research and clinical work should aim to further examine the use of telehealth among postpartum individuals.
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Affiliation(s)
- Helen B Gomez
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
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