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Bisson C, Patel E, Mueller A, Suresh S, Duncan C, Premkumar A, Shahul S, Rana S. Extended postpartum outcomes with systematic treatment of and management of postpartum hypertension program. Pregnancy Hypertens 2024; 37:101138. [PMID: 38878602 DOI: 10.1016/j.preghy.2024.101138] [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: 02/18/2024] [Revised: 04/29/2024] [Accepted: 06/09/2024] [Indexed: 09/15/2024]
Abstract
OBJECTIVE The purpose of this study was to examine the long-term effect of a quality improvement initiative at one-year post delivery. STUDY DESIGN This was a retrospective study of 1480 patients who delivered between October 2018 and June 2020 at the study institution and were enrolled in the Systematic Treatment and Management of PostPartum Hypertension Program (STAMPP). Patients received standardized cuffs, education, and follow-up. At the six-week postpartum follow-up, patients were again given instructions to establish follow-up. MAIN OUTCOME MEASURES The primary outcome was a visit with a primary care physician (PCP) or cardiologist between 6 weeks and 1 year postpartum. RESULTS A total of 939 (63 %) patients had some follow-up within twelve months. Of these, 113 (12 %) and 175 (19 %) had follow-up with cardiology and primary care providers, respectively. Patients with no follow-up were more likely to have public aid (73.9 % vs 60.3 %; p < 0.001). 77 % identified as Black, with only 12 % of this cohort following up with cardiology and 13 % with a PCP. CONCLUSIONS Despite specific counseling about long term follow-up, a minority of patients completed one year follow-up, notably amongst Black patients and those with public insurance. Further work is needed to optimize long-term follow-up after HDP to reduce the prevalence of cardiovascular disease, especially amongst high-risk patients.
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Affiliation(s)
- Courtney Bisson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, United States
| | - Easha Patel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, United States
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sunitha Suresh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NorthShore University Health System, IL, United States
| | - Colleen Duncan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, United States
| | - Ashish Premkumar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, United States
| | - Sajid Shahul
- Department of Anesthesia, The University of Chicago Medicine, Chicago, IL, United States
| | - Sarosh Rana
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, United States.
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Lemon LS, Quinn B, Binstock A, Larkin JC, Simhan HN, Hauspurg A. Clinical Outcomes Associated With a Remote Postpartum Hypertension Monitoring Program. Obstet Gynecol 2024; 144:377-385. [PMID: 38954821 PMCID: PMC11326966 DOI: 10.1097/aog.0000000000005665] [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: 03/19/2024] [Accepted: 05/23/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE To evaluate differences in health care utilization and guideline adherence for postpartum individuals with hypertensive disorders of pregnancy (HDP) who are engaged in a remote monitoring program, compared with usual care. METHODS This was a retrospective cohort study of postpartum individuals with HDP who delivered between March 2019 and June 2023 at a single institution. The primary exposure was enrollment in a remote hypertension management program that relies on patient home blood pressure (BP) measurement and centralized nursing team management. Patients enrolled in the program were compared with those receiving usual care. Outcomes included postpartum readmission, office visit within 6 weeks postpartum, BP measurement within 10 days, and initiation of antihypertensive medication. We performed multivariable logistic and conditional regression in a propensity score matched cohort. Propensity scores, generated by modeling likelihood of program participation, were assessed for even distribution by group, ensuring standardized bias of less than 10% after matching. RESULTS Overall, 12,038 eligible individuals (6,556 participants, 5,482 in the control group) were included. Program participants were more likely to be White, commercially insured, be diagnosed with preeclampsia, and have higher prenatal and inpatient postpartum BPs. Differences in baseline factors were well-balanced after implementation of propensity score. Program enrollment was associated with lower 6-week postpartum readmission rates, demonstrating 1 fewer readmission for every 100 individuals in the program (propensity score-matched adjusted risk difference [aRD] -1.5, 95% CI, -2.6 to -0.46; adjusted risk ratio [aRR] 0.78, 95% CI, 0.65-0.93). For every 100 individuals enrolled in the program, 85 more had a BP recorded within 10 days (propensity score-matched aRD 85.4, 95% CI, 84.3-86.6), and six more had a 6-week postpartum office visit (propensity score-matched aRD 5.7, 95% CI, 3.9-7.6). Program enrollment was also associated with increased initiation of an antihypertensive medication postpartum (propensity score-matched aRR 4.44, 95% CI, 3.88-5.07). CONCLUSION Participation in a postpartum remote BP monitoring program was associated with fewer postpartum hospital readmissions, higher attendance at postpartum visits, improved guideline adherence, and higher rates of antihypertensive use.
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Affiliation(s)
- Lara S Lemon
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, and Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Chen MT, Vollmer BL, Blyler CA, Cameron NA, Miller EC, Huang Y, Friedman AM, Wright JD, Boehme AK, Bello NA. Antihypertensive medication prescription dispensation among pregnant women in the United States: A cohort study. Am Heart J 2024; 278:5-13. [PMID: 39178979 DOI: 10.1016/j.ahj.2024.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 08/06/2024] [Accepted: 08/16/2024] [Indexed: 08/26/2024]
Abstract
IMPORTANCE Hypertension is increasingly common in pregnancy capable individuals, yet there is limited data on antihypertensive medication dispensation in peripartum individuals. OBJECTIVE To describe antihypertensive medication dispensation from preconception through the first year postpartum. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the Truven Health Market Scan administrative data from 2008 to 2014 to identify women in the United States with commercial or government health insurance, aged 15-54, free from heart disease, who experienced a pregnancy and filled at least 1 prescription for an antihypertensive medication between 3 months prior to conception and 12 months after the end of the pregnancy. MAIN OUTCOMES AND MEASURES We describe antihypertensive dispensation patterns (continuation, initiation, and discontinuation) by medication class during 5 time periods: preconception, first, second, and third trimesters, and the first year postpartum. RESULTS Of 1,058,521 pregnancies, 108,614 (10.3%) were exposed to at least 1 antihypertensive medication dispensation. The most commonly dispensed medications across all periods combined were adrenergic blockers, calcium channel blockers (CCBs), and diuretics. Renin-angiotensin-aldosterone system (RAAS) inhibitors were the third most dispensed medication class in the preconception period (26.4%), and fills decreased to 5.7% and 1.7% in the second and third trimesters, respectively. Of the women with chronic hypertension who filled at least 1 prescription prior to conception, 8.4% were not dispensed an antihypertensive medication during the first year after delivery. CONCLUSIONS AND RELEVANCE Antihypertensive prescription dispensation of both preferred and potentially harmful agents is common in pregnancy capable individuals. Patterns of dispensation suggest room for improvement in the treatment of chronic hypertension after a pregnancy.
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Affiliation(s)
- Melanie T Chen
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Brandi L Vollmer
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Columbia University Irving Medical Center, New York, NY
| | - C Adair Blyler
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Natalie A Cameron
- Department of Medicine, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Yongmei Huang
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Amelia K Boehme
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Natalie A Bello
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
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Countouris ME, Shapero KS, Swabe G, Hauspurg A, Davis EM, Magnani JW. Association of Race and Ethnicity and Social Factors With Postpartum Primary Care or Cardiology Follow-Up Visits Among Individuals With Preeclampsia. J Am Heart Assoc 2024; 13:e033188. [PMID: 39109511 DOI: 10.1161/jaha.123.033188] [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: 10/23/2023] [Accepted: 07/02/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Preeclampsia is associated with increased cardiovascular morbidity and death. Primary care or cardiology follow-up, in complement to routine postpartum obstetric care, provides an essential opportunity to address cardiovascular risk. Prior studies investigating racial differences in the recommended postpartum follow-up have incompletely assessed the influence of social factors. We hypothesized that racial and ethnic differences in follow-up with a primary care provider or cardiologist would be modified by income and education. METHODS AND RESULTS We identified adult individuals with preeclampsia (September 2014 to September 2019) in a national administrative database. We compared occurrence of a postpartum visit with a primary care provider or cardiologist within 1 year after delivery by race and ethnicity using multivariable logistic regression models. We examined whether education or income modified the association between race and ethnicity and the likelihood of follow-up. Of 18 050 individuals with preeclampsia (aged 31.8±5.7 years), Black individuals (11.7%) had lower odds of primary care provider or cardiology follow-up within 1 year after delivery compared with White individuals (adjusted odds ratio, 0.77 [95% CI, 0.70-0.85]) as did Hispanic individuals (14.8%; adjusted odds ratio, 0.79 [95% CI, 0.73-0.87]). Black and Hispanic individuals with higher educational attainment were more likely to have follow-up than those with lower educational attainment (P for interaction=0.033) as did those in higher income brackets (P for interaction=0.006). CONCLUSIONS We identified racial and ethnic differences in primary care or cardiology follow-up in the year postpartum among individuals diagnosed with preeclampsia, a disparity that may be modified by social factors. Enhanced system-level interventions are needed to reduce barriers to follow-up care.
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Affiliation(s)
- Malamo E Countouris
- Division of Cardiology, Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Kayle S Shapero
- Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University Providence RI USA
| | - Gretchen Swabe
- Division of Cardiology, Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology, and Reproductive Sciences University of Pittsburgh Pittsburgh PA USA
| | - Esa M Davis
- Department of Family and Community Medicine University of Maryland Baltimore MD USA
| | - Jared W Magnani
- Division of Cardiology, Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA USA
- Center for Research on Health Care University of Pittsburgh School of Medicine Pittsburgh PA USA
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Jarlenski M, Kennedy S, Johnson A, Hale C, D'Angelo Z, Nedhari A, Coffee G, Chappell-McPhail M, Green K, Méndez DD, Goetschius LG, Gareau S, Ashford K, Barnes AJ, Ahrens KA, Zivin K, Mosley E, Tang L. Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs. Health Res Policy Syst 2024; 22:98. [PMID: 39118099 PMCID: PMC11308708 DOI: 10.1186/s12961-024-01185-9] [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: 05/01/2024] [Accepted: 07/22/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity. METHODS We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes. DISCUSSION Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).
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Affiliation(s)
- Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, 130 DeSoto St, A619, Pittsburgh, PA, 15261, United States of America.
- Center for Innovative Research On Gender Health Equity, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Susan Kennedy
- AcademyHealth, Washington, DC, United States of America
| | | | - Caroline Hale
- AcademyHealth, Washington, DC, United States of America
| | - Zoe D'Angelo
- AcademyHealth, Washington, DC, United States of America
| | - Aza Nedhari
- Mamatoto Village, Washington, DC, United States of America
| | - Gerria Coffee
- Genesis Birth Services, Williamsport, PA, United States of America
- PA Doula Commission, Landsdowne, PA, United States of America
| | | | - Kiddada Green
- Black Mothers' Breastfeeding Association, Detroit, MI, United States of America
| | - Dara D Méndez
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, United States of America
- Center for Health Equity, University of Pittsburgh School of Public Health, Pittsburgh, PA, United States of America
| | - Leigh G Goetschius
- The Hilltop Institute, University of Maryland, Baltimore County, Baltimore, MD, United States of America
| | - Sarah Gareau
- Institute for Families in Society, College of Social Work, University of South Carolina, Columbia, SC, United States of America
| | - Kristin Ashford
- College of Nursing, University of Kentucky, Lexington, United States of America
| | - Andrew J Barnes
- Health Policy, School of Population Health, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Katherine A Ahrens
- Public Health Program, Muskie School of Public Service, University of Southern Maine, Portland, ME, United States of America
| | - Kara Zivin
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America
| | - Elizabeth Mosley
- Center for Innovative Research On Gender Health Equity, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA, United States of America
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Geissler KH, Jeung C, Attanasio LB. Preventive Primary Care in the Postpartum Year: The Role of Medicaid Delivery System Reform. Am J Prev Med 2024; 67:184-192. [PMID: 38484901 PMCID: PMC11260532 DOI: 10.1016/j.amepre.2024.03.005] [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] [Received: 11/08/2023] [Revised: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Preventive and primary care in the postpartum year is critical for future health and may be increased by primary care focused delivery system reform including implementation of Medicaid Accountable Care Organizations (ACO). This study examined associations of Massachusetts Medicaid ACO implementation with preventive visits in the postpartum year. METHODS The Massachusetts All-Payer Claims Database was used to identify births to privately-insured or Medicaid ACO-eligible individuals from January 1, 2016 to February 28, 2019. Comparing these groups before and after implementation, a propensity score weighted difference-in-difference design was used to analyze associations of Medicaid ACO implementation with any preventive care visit and any primary care physician (PCP) preventive visit within one year postpartum, controlling for other characteristics. Analyses were performed in 2023 and 2024. RESULTS Of the 110,601 births in the study population, 35.5% had any preventive care visit and 23.0% had any preventive PCP visit in the year postpartum, with higher rates of preventive visits among privately-insured individuals. In adjusted difference-in-difference analyses, relative to the pre-period, there was a 2.7 percentage point (pp) decrease (95% confidence interval [CI]: -4.3pp, -1.2pp) and 3.5 pp decrease (95% CI: -4.9pp, -2.0pp) in use of any preventive visits and any PCP preventive visits, respectively, for Medicaid-insured versus privately-insured individuals after ACO implementation. CONCLUSIONS Implementation of Massachusetts Medicaid ACOs was associated with decreases in receipt of preventive visits and preventive PCP visits for Medicaid-insured individuals relative to privately-insured individuals. Medicaid ACOs should consider potential implications of primary care access in the postpartum year for health across the lifecourse.
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Affiliation(s)
- Kimberley H Geissler
- Department of Healthcare Delivery and Population Sciences, UMass Chan Medical School-Baystate, Springfield, MA
| | - Chanup Jeung
- Department of Health Policy, Management and Behavior, School of Public Health, State University of New York at Albany, Albany, NY
| | - Laura B Attanasio
- Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, MA.
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Daubert MA, Stebbins A, Peragallo-Urrutia R, Chiswell K, Loop MS, Harding C, Price T, Wang TY. Early postpartum blood pressure screening is associated with increased detection of cardiovascular risk factors in women with hypertensive disorders of pregnancy. Am Heart J 2024; 273:130-139. [PMID: 38582139 PMCID: PMC11162911 DOI: 10.1016/j.ahj.2024.03.014] [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] [Received: 11/27/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP), including gestational hypertension, preeclampsia, and eclampsia, are risk factors for cardiovascular (CV) disease. Guidelines recommend that women with HDP be screened for the development of hypertension (HTN) within 6-12 months postpartum. However, the extent to which this early blood pressure (BP) screening is being performed and the impact on detection of CV risk factors is unknown. METHODS Women with HDP and without pre-existing hypertension (HTN) who had at least 6 months of clinical follow-up were categorized by postpartum BP screening status: early BP screen (6-12 months after delivery) or late BP screen (≥12 months after delivery). Multivariable logistic regression identified factors associated with early screening. Multivariable Cox proportional hazards modeling examined the association between early screening and detection of incident CV risk factors: HTN, prediabetes, diabetes mellitus type 2, or hyperlipidemia. RESULTS Among 4194 women with HDP, 1172 (28%) received early BP screening. Older age, pre-existing hyperlipidemia, diabetes, sickle cell disease, hypothyroidism, gestational diabetes, and delivery during or after 2014 were independently associated with early BP screening, whereas Hispanic ethnicity was associated with late BP screening. Early BP screening was most commonly performed at a primary care visit. After a median follow-up of 3.7 years, 1012 (24%) women had at least 1 new risk factor detected. Even after adjustment for baseline risk, women receiving early BP screening had a significantly higher rate of incident CV risk factor detection than women receiving late BP screening (56% vs 28%; adj. HR 2.70, 95%CI: 2.33-3.23, P < .001). CONCLUSIONS Early postpartum BP screening was performed in a minority of women with HDP, but was associated with greater detection of CV risk factors. More intensive postpartum CV screening and targeted interventions are needed to optimize CV health in this high-risk population of women with HDP.
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Affiliation(s)
- Melissa A Daubert
- Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | | | | | | | | | | | | | - Tracy Y Wang
- Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
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Clapp MA, Ray A, Liang P, James KE, Ganguli I, Cohen JL. Postpartum Primary Care Engagement Using Default Scheduling and Tailored Messaging: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2422500. [PMID: 39012630 PMCID: PMC11252898 DOI: 10.1001/jamanetworkopen.2024.22500] [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] [Received: 03/04/2024] [Accepted: 05/02/2024] [Indexed: 07/17/2024] Open
Abstract
Importance More than 30% of pregnant people have at least 1 chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face major barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition. Objective To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps. Design, Setting, and Participants An individual-level randomized clinical trial was conducted from November 3, 2022, to October 11, 2023, at 1 hospital-based and 5 community-based outpatient obstetric clinics affiliated with a large academic medical center. Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes, chronic hypertension, gestational diabetes, or pregnancy-related hypertension and a primary care practitioner (PCP) listed in their electronic health record. Intervention A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages. Main Outcome and Measures Completion of a PCP visit for routine or chronic condition care within 4 months of delivery was the primary outcome, ascertained directly by reviewing the patient's electronic health record approximately 5 months after their estimated due date. Intention-to-treat analysis was conducted. Results A total of 360 patients were randomized (control, 176; intervention, 184). Individuals had a mean (SD) age of 34.1 (4.9) years and median gestational age of 36.3 (IQR, 34.0-38.6) weeks at enrollment. The distribution of self-reported race and ethnicity was 6.8% Asian, 7.4% Black, 68.6% White, and 15.0% multiple races or other. Most participants (75.4%) had anxiety or depression, 16.1% had a chronic or pregnancy-related hypertensive disorder, 19.5% had preexisting or gestational diabetes, and 40.8% had a prepregnancy body mass index of 30 or greater. Medicaid was the primary payer for 21.2% of patients. Primary care practitioner visit completion within 4 months occurred in 22.0% (95% CI, 6.4%-28.8%) of individuals in the control group and 40.0% (95% CI, 33.1%-47.4%) in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95% CI, 9.1-28.2 percentage points). Intervention participants also had fewer postpartum readmissions (1.7% vs 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8% vs 28.3%), weight assessment (42.8% vs 27.7%), and depression screening (32.8% vs 16.8%). Conclusions and Relevance The findings of this randomized clinical trial suggest that the current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and well-being. Trial Registration ClinicalTrials.gov Identifier: NCT05543265.
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Affiliation(s)
- Mark A. Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Alaka Ray
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Pichliya Liang
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
| | - Kaitlyn E. James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Lumsden R, Page CB, Phelan M, Wheeler S, Pagidipati N. Longitudinal Management of Cardiovascular Risk Factors Among Postpartum Women. J Womens Health (Larchmt) 2024; 33:853-862. [PMID: 38533846 DOI: 10.1089/jwh.2023.0461] [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] [Indexed: 03/28/2024] Open
Abstract
Background: Pregnancy-related cardiovascular (CV) conditions, including hypertensive disorders of pregnancy (HDP) and gestational diabetes (GDM), are associated with increased long-term CV risk. Methods: This retrospective cohort study defined the prevalence of HDP and GDM within a large, academic health system in the southeast United States between 2012 and 2015 and described health care utilization and routine CV screening up to 1-year following delivery among those with pregnancy-related CV conditions. Rates of follow-up visits and blood pressure, hemoglobin A1c (HbA1c), and lipid screening in the first postpartum year were compared by provider type and pregnancy-related CV condition. Results: Of the 6027 deliveries included, 20% were complicated by HDP and/or GDM. Rates of pre-pregnancy CV risk factors were high, with a significantly higher proportion of pre-pregnancy obesity among women with HDP than in normal pregnancies. Those with both HDP/GDM had the highest rates of follow-up by 1-year postpartum, yet only half of those with any pregnancy-related CV condition had any follow-up visit after 12 weeks. Although most (70%) of those with HDP had postpartum blood pressure screening, less than one-third of those with GDM had a repeat HbA1c by 12 months. Overall, postpartum lipid screening was rare (<20%). Conclusion: There is a high burden of pregnancy-related CV conditions in a large U.S. academic health system. Although overall rates of follow-up in the early postpartum period were high, gaps in longitudinal follow-up exist. Low rates of CV risk factor follow-up at 1 year indicate a missed opportunity for early CV prevention.
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Affiliation(s)
- Rebecca Lumsden
- Department of Medicine (General Internal Medicine), Duke University School of Medicine, Durham, North Carolina, USA
| | - Courtney B Page
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Sarahn Wheeler
- Department of Obstetrics and Gynecology (Maternal Fetal Medicine), Duke University School of Medicine, Durham, North Carolina, USA
| | - Neha Pagidipati
- Department of Medicine (Cardiology), Duke University School of Medicine, Durham, North Carolina, USA
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Phillips SEK, Celi AC, Margo J, Wehbe A, Karlage A, Zera CA. Improving Care Beyond Birth: A Qualitative Study of Postpartum Care After High-Risk Pregnancy. J Womens Health (Larchmt) 2024. [PMID: 38860345 DOI: 10.1089/jwh.2024.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024] Open
Abstract
Background: The postpartum period is a window to engage birthing people in their long-term health and facilitate connections to comprehensive care. However, postpartum systems often fail to transition high-risk patients from obstetric to primary care. Exploring patient experiences can be helpful for optimizing systems of postpartum care. Methods: This is a qualitative study of high-risk pregnant and postpartum individuals. We conducted in-depth interviews with 20 high-risk pregnant or postpartum people. Interviews explored personal experiences of postpartum care planning, coordination of care between providers, and patients' perception of ideal care transitions. We performed thematic analysis using the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change as a framework. COM-B allowed for a formal structure to assess participants' ability to access postpartum care and primary care reengagement after delivery. Results: Participants universally identified difficulty accessing primary care in the postpartum period, with the most frequently reported barriers being lack of knowledge and supportive environments. Insufficient preparation, inadequate prenatal counseling, and lack of standardized care transitions were the most significant barriers to primary care reengagement. Participants who most successfully engaged in primary care had postpartum care plans, coordination between obstetric and primary care, and access to material resources. Conclusions: High-risk postpartum individuals do not receive effective counseling on the importance of primary care engagement after delivery. System-level challenges and lack of care coordination also hinder access to primary care. Future interventions should include prenatal education on the benefits of primary care follow-up, structured postpartum planning, and system-level improvements in obstetric and primary care provider communication.
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Affiliation(s)
- Sara E K Phillips
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ann C Celi
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Divisions of General Medicine and Women's Health, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Judy Margo
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexandra Wehbe
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ami Karlage
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chloe A Zera
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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11
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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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12
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Clapp MA, Ray A, Liang P, James KE, Ganguli I, Cohen J. Increasing Postpartum Primary Care Engagement through Default Scheduling and Tailored Messaging : A Randomized Clinical Trial. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.21.24301585. [PMID: 38633772 PMCID: PMC11023680 DOI: 10.1101/2024.01.21.24301585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Importance Over 30% of pregnant people have at least one chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face significant barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition. Objective To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps. Design Individual-level randomized controlled trial conducted from November 3, 2022 to October 11, 2023. Setting One hospital-based and five community-based outpatient obstetric clinics affiliated with a large academic medical center. Participants Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes mellitus, chronic hypertension, gestational diabetes, or pregnancy-related hypertension, and a primary care practitioner (PCP) listed in their electronic health record (EHR). Intervention A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages. Main Outcome Completion of a PCP visit for routine or chronic condition care within 4 months of delivery. Results 360 patients were randomized (Control: N=176, Intervention: N=184). Individuals had mean (SD) age 34.1 (4.9) years and median gestational age of 36.3 weeks (interquartile range (IQR) 34.0-38.6 weeks) at enrollment. The distribution of self-reported races was 7.4% Asian, 6.8% Black, 15.0% multiple races or "Other," and 68.6% White. Most (75.8%) participants had anxiety or depression, 15.9% had a chronic or pregnancy-related hypertensive disorder, 19.8% had pre-existing or gestational diabetes, and 40.4% had a pre-pregnancy BMI ≥30 kg/m2. Medicaid was the primary payer for 21.9% of patients. PCP visit completion within 4 months occurred in 22.0% in the control group and 40.0% in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95%CI 10.7-29.1). Intervention participants also had fewer postpartum readmissions (1.7 vs. 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8 vs. 28.3%), weight assessment (42.8 vs. 27.7%), and depression screening (32.8 vs. 16.8%). Conclusions and Relevance In this randomized trial of pregnant individuals with or at risk for chronic health conditions, default PCP visit scheduling, tailored messages, and reminders substantially improved postpartum primary care engagement. The current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and wellbeing. Trial Registration NCT05543265.
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Affiliation(s)
- Mark A Clapp
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Alaka Ray
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Kaitlyn E James
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ishani Ganguli
- Harvard Medical School, Boston, MA
- Brigham & Women's Hospital, Boston MA
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13
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Lewey J, Beckie TM, Brown HL, Brown SD, Garovic VD, Khan SS, Miller EC, Sharma G, Mehta LS. Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e330-e346. [PMID: 38346104 PMCID: PMC11185178 DOI: 10.1161/cir.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.
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14
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Gregory EF, Beidas RS, Fiks AG, Lorch SA, Levine LD, Rubin DM, Maddox AI, O'Sullivan AL, Wu KK, Cronholm PF. Acceptability of Dyad Care Management After Preterm Birth: A Qualitative Study. Matern Child Health J 2024; 28:351-361. [PMID: 37980700 PMCID: PMC11197049 DOI: 10.1007/s10995-023-03848-5] [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] [Accepted: 11/02/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES Care management programs for medically complex infants interact with parents after complicated pregnancies, when gaps in maternal health care are well documented. These care managers may have the relationships and skills to promote postpartum and interconception health and health care access. It is unknown whether expanding these care management models to address maternal needs would be acceptable. METHODS We conducted qualitative interviews with women with a history of preterm birth and clinicians. For women with a history of preterm birth, additional inclusion criteria were Medicaid-insured infant in one health system and English proficiency. We purposively oversampled women whose infants received care management. Clinicians worked in two geographically adjacent health systems. Interviews explored priorities after preterm birth and perceived acceptability of mother-infant dyad care management. Interviews were audio recorded, transcribed, and coded following an integrated approach in which we applied a priori codes and captured emergent themes. RESULTS We interviewed 33 women (10/2018-7/2021) and 24 clinicians (3/2021-8/2021). Women were predominantly non-Hispanic Black, and 15 had infants receiving care management. Clinicians included physicians, nurses, and social workers from Pediatrics, Obstetrics, and Family Medicine. Subgroups converged thematically, finding care management acceptable. Tailoring programs to address stress and sleep, emphasizing care managers with strong interpersonal skills and shared experiences with care management users, and program flexibility would contribute to acceptability. CONCLUSIONS FOR PRACTICE Dyad care management after preterm birth is acceptable to potential program end-users and clinicians. Dyad health promotion may contribute to improved birth outcomes, infant, and parent health.
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Affiliation(s)
- Emily F Gregory
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.
| | - Rinad S Beidas
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Alexander G Fiks
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Scott A Lorch
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Lisa D Levine
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine Research Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - David M Rubin
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Adya I Maddox
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Ann L O'Sullivan
- University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - Katherine K Wu
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Peter F Cronholm
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
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15
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Kilkenny K, Frishman W. Preeclampsia's Cardiovascular Aftermath: A Comprehensive Review of Consequences for Mother and Offspring. Cardiol Rev 2024:00045415-990000000-00188. [PMID: 38189425 DOI: 10.1097/crd.0000000000000639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Preeclampsia (PE), a multisystem hypertensive disorder affecting 2-8% of pregnancies, has emerged as a novel risk factor for cardiovascular disease (CVD) in affected mothers and in their offspring. Between 10 and 15 years following gestation, women with a history of PE have double the risk of CVD, nearly 4 times the risk of hypertension, and increased all-cause mortality. Offspring exposed to PE in utero carry an increased risk of CVD and congenital heart defects. Due to the multifactorial nature of both PE and CVD, a clear dependency has been difficult to establish. The interplay between CVD and PE is an area of active investigation, likely involving placental, genetic, and epigenetic factors resulting in enduring endothelial, vascular, and immune dysfunction. Fetal developmental programming induced by adverse intrauterine environments, epigenetic changes triggered by oxidative stress, and underlying genetic predisposition play pivotal roles in the development of CVD in offspring exposed to PE. Though the literature has discussed the cardiovascular outcomes associated with PE for nearly a decade, patient risk perception and health care provider awareness remain low, representing a substantial missed opportunity for early intervention in this vulnerable population. This review article will discuss the pathophysiology of preeclampsia, its intersection with CVD, and the long-term cardiovascular consequences for affected mothers and their offspring. Our objective is to increase health care provider awareness and garner greater research interest in this important topic.
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Affiliation(s)
| | - William Frishman
- From the New York Medical College, School of Medicine, Valhalla, NY
- Department of Medicine, Westchester Medical Center, Valhalla, NY
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16
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Bose-Brill S, Gillespie SL, Venkatesh KK. Can We Implement Multispecialty Mother-Infant Dyadic Care to Systematize Interpregnancy Services After a Preterm Birth? WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2023; 4:651-655. [PMID: 38155872 PMCID: PMC10754421 DOI: 10.1089/whr.2023.0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Seuli Bose-Brill
- Combined Internal Medicine and Pediatrics Section, Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Shannon L. Gillespie
- The Martha S. Pitzer Center for Women, Children, and Youth, College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Kartik K. Venkatesh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, USA
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17
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Arntzen E, Jøsendal R, Sandsæter HL, Horn J. Postpartum follow-up of women with preeclampsia: facilitators and barriers - A qualitative study. BMC Pregnancy Childbirth 2023; 23:833. [PMID: 38049716 PMCID: PMC10694896 DOI: 10.1186/s12884-023-06146-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/20/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Pregnancy causes physiological changes to the maternal organ systems that can be regarded as a cardiometabolic stress test for women. Preeclampsia, a pregnancy complication characterized by new onset of hypertension in combination with proteinuria or end-organ dysfunction, affects approximately 2-8% of pregnancies. Adverse pregnancy outcomes, including preeclampsia, have been described as a failed stress test and have been consistently linked with increased risk of cardiovascular disease later in life. The postpartum period is therefore often regarded as a window of opportunity for cardiovascular disease prevention. However, we lack knowledge about how women with preeclampsia experience current postpartum care in the Norwegian health system. The aim of this qualitative study is to uncover women's perspectives and preferences regarding postpartum follow-up. METHODS Semi-structured telephone interviews were conducted with 17 women following a six-month lifestyle intervention study. Participants were 9-20 months postpartum, following a pregnancy complicated by preeclampsia. Data were analyzed using Malterud's systematic text condensation. RESULTS We identified five themes, each with 2-3 subthemes, that demonstrate how women with recent preeclampsia experience postpartum follow-up: (1) fear and uncertainty (a body out of balance and facing an uncertain future), (2) a conversation on lifestyle - not really that difficult (preeclampsia as a gateway, a respectful approach, and a desire for more constructive feedback), (3) when your own health is not a priority (a new everyday life, out of focus, and lack of support), (4) motivation for lifestyle changes (an eye opener, lack of intrinsic motivation, and a helping hand), and (5) lack of structured and organized follow-up (there should be a proper system, a one-sided follow-up care, and individual variation in follow-up care). CONCLUSIONS Findings from this study highlight the need for more systematic postpartum follow-up for women after a pregnancy complicated by preeclampsia. Further research is required to explore the potential use of standardized guidelines and routine invitations to postpartum care. Furthermore, exploring health care professionals' experiences is crucial to ensure their engagement in postpartum care after complicated pregnancies.
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Affiliation(s)
- Eirin Arntzen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postbox 8905, NO-7491, Trondheim, Norway
| | - Ranveig Jøsendal
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postbox 8905, NO-7491, Trondheim, Norway
| | - Heidi Linn Sandsæter
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postbox 8905, NO-7491, Trondheim, Norway
- Department of Obstetrics and Gynecology, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Julie Horn
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postbox 8905, NO-7491, Trondheim, Norway.
- Department of Obstetrics and Gynecology, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.
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18
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Srialluri N, Surapaneni A, Chang A, Mackeen AD, Paglia MJ, Grams ME. Preeclampsia and Long-term Kidney Outcomes: An Observational Cohort Study. Am J Kidney Dis 2023; 82:698-705. [PMID: 37516302 PMCID: PMC10818021 DOI: 10.1053/j.ajkd.2023.04.010] [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: 11/14/2022] [Revised: 04/04/2023] [Accepted: 04/22/2023] [Indexed: 07/31/2023]
Abstract
RATIONALE & OBJECTIVE Preeclampsia is a pregnancy-related complication characterized by acute hypertension and end-organ dysfunction. We evaluated the long-term association between preeclampsia and the risk of developing chronic hypertension and kidney disease. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 27,800 adults with deliveries in the Geisinger Health System between 1996 and 2019. EXPOSURE Preeclampsia. OUTCOME Hypertension, reduced estimated glomerular filtration rate (eGFR)<60mL/min/1.73m2), and albuminuria>300mg/g. ANALYTICAL APPROACH Propensity-score matching and Cox proportional hazards models to evaluate the association between preeclampsia and incident hypertension, reduced eGFR, and albuminuria. RESULTS Of 27,800 adults with pregnancies during the study period (mean age, 28 years; 3% Black race), 2,977 (10.7%) had at least 1 pregnancy complicated by preeclampsia. After matching for multiple characteristics, individuals with preeclampsia had a higher risk of developing chronic hypertension (HR, 1.77 [95% CI, 1.45-2.16]), eGFR<60mL/min/1.73m2 (HR, 3.23 [95% CI, 1.64-6.36]), albuminuria (HR, 3.60 [95% CI, 2.38-5.44]), and a subsequent episode of preeclampsia (HR, 24.76 [95% CI, 12.47-48.36]), compared with matched controls without preeclampsia. Overall, postpartum follow-up testing was low. In the first 6 months after delivery, 31% versus 14% of individuals with and without preeclampsia had serum creatinine tests, respectively, and testing for urine protein was the same in both groups, with only 26% having follow-up testing. LIMITATIONS Primarily White study population, observational study, reliance on ICD codes for medical diagnosis. CONCLUSIONS Individuals with a pregnancy complicated by preeclampsia had a higher risk of hypertension, reduced eGFR, and albuminuria compared with individuals without preeclampsia. PLAIN-LANGUAGE SUMMARY Preeclampsia is a significant contributor to perinatal and maternal morbidity and is marked by new-onset hypertension and end-organ damage, including acute kidney injury or proteinuria. To gain insight into the long-term kidney effects of the disease, we compared adults with deliveries complicated by preeclampsia with those without preeclampsia in the Geisinger Health System, while also assessing postpartum testing rates. Our results demonstrate that pregnant individuals with preeclampsia are at a heightened risk for future hypertension, reduced eGFR, and albuminuria, with overall low rates of postpartum testing among both individuals with and without preeclampsia. These findings underscore the need to consider preeclampsia as an important risk factor for the development of chronic kidney disease. Further studies are required to determine optimal postpreeclampsia monitoring strategies.
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Affiliation(s)
- Nityasree Srialluri
- Division of Nephrology, Department of Medicine, Johns Hopkins University Baltimore, Maryland; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University Baltimore, Maryland.
| | - Aditya Surapaneni
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University Baltimore, Maryland; Division of Precision Medicine, Department of Medicine, New York University, New York, New York
| | - Alexander Chang
- Kidney Health Research Institute, Danville, Pennsylvania; Department of Population Health Sciences, Geisinger, Danville, Pennsylvania
| | - A Dhanya Mackeen
- Division of Maternal-Fetal Medicine, Women's Health Service Line, Danville, Pennsylvania
| | - Michael J Paglia
- Division of Maternal-Fetal Medicine, Women's Health Service Line, Danville, Pennsylvania
| | - Morgan E Grams
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University Baltimore, Maryland; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University Baltimore, Maryland; Division of Precision Medicine, Department of Medicine, New York University, New York, New York
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19
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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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20
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Barry MJ, Nicholson WK, Silverstein M, Cabana MD, Chelmow D, Coker TR, Davis EM, Donahue KE, Jaén CR, Li L, Ogedegbe G, Rao G, Ruiz JM, Stevermer J, Tsevat J, Underwood SM, Wong JB. Screening for Hypertensive Disorders of Pregnancy: US Preventive Services Task Force Final Recommendation Statement. JAMA 2023; 330:1074-1082. [PMID: 37721605 DOI: 10.1001/jama.2023.16991] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Importance Hypertensive disorders of pregnancy are among the leading causes of maternal morbidity and mortality in the US. The rate of hypertensive disorders of pregnancy has been increasing from approximately 500 cases per 10 000 deliveries in 1993 to 1021 cases per 10 000 deliveries in 2016 to 2017. Objective The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertensive disorders of pregnancy. Population Pregnant persons without a known diagnosis of a hypertensive disorder of pregnancy or chronic hypertension. Evidence Assessment The USPSTF concludes with moderate certainty that screening for hypertensive disorders in pregnancy with blood pressure measurements has substantial net benefit. Recommendation The USPSTF recommends screening for hypertensive disorders in pregnant persons with blood pressure measurements throughout pregnancy. (B recommendation).
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Affiliation(s)
| | | | | | | | | | | | - Esa M Davis
- University of Maryland School of Medicine, Baltimore
| | | | | | - Li Li
- University of Virginia, Charlottesville
| | | | - Goutham Rao
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Joel Tsevat
- University of Texas Health Science Center, San Antonio
| | | | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
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21
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Chan Y, Cheung BMY. Cardiovascular Health in Women With Pregnancy-Related Risk Enhancers: Putting Evidence Into Action. J Am Heart Assoc 2023; 12:e031962. [PMID: 37642033 PMCID: PMC10547356 DOI: 10.1161/jaha.123.031962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Yap‐Hang Chan
- Department of Medicine, School of Clinical MedicineThe University of Hong KongHong Kong SARChina
- Experimental Medicine and Immunotherapeutics, Addenbrooke’s HospitalUniversity of CambridgeCambridgeUnited Kingdom
| | - Bernard M. Y. Cheung
- Department of Medicine, School of Clinical MedicineThe University of Hong KongHong Kong SARChina
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22
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Aqua JK, Ford ND, Pollack LM, Lee JS, Kuklina EV, Hayes DK, Vaughan AS, Coronado F. Timing of outpatient postpartum care utilization among women with chronic hypertension and hypertensive disorders of pregnancy. Am J Obstet Gynecol MFM 2023; 5:101051. [PMID: 37315845 PMCID: PMC10527898 DOI: 10.1016/j.ajogmf.2023.101051] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND The postpartum period represents an opportunity to assess the cardiovascular health of women who experience chronic hypertension or hypertensive disorders of pregnancy. OBJECTIVE This study aimed to determine whether women with chronic hypertension or hypertensive disorders of pregnancy access outpatient postpartum care more quickly compared to women with no hypertension. STUDY DESIGN We used data from the Merative MarketScan Commercial Claims and Encounters Database. We included 275,937 commercially insured women aged 12 to 55 years who had a live birth or stillbirth delivery hospitalization between 2017 and 2018 and continuous insurance enrollment from 3 months before the estimated start of pregnancy to 6 months after delivery discharge. Using the International Classification of Diseases Tenth Revision Clinical Modification codes, we identified hypertensive disorders of pregnancy from inpatient or outpatient claims from 20 weeks gestation through delivery hospitalization and identified chronic hypertension from inpatient or outpatient claims from the beginning of the continuous enrollment period through delivery hospitalization. Distributions of time-to-event survival curves (time-to-first outpatient postpartum visit with a women's health provider, primary care provider, or cardiology provider) were compared between the hypertension types using Kaplan-Meier estimators and log rank tests. We used Cox proportional hazards models to estimate adjusted hazard ratios and 95% confidence intervals. Time points of interest (3, 6, and 12 weeks) were evaluated per clinical postpartum care guidelines. RESULTS Among commercially insured women, the prevalences of hypertensive disorders of pregnancy, chronic hypertension, and no documented hypertension were 11.7%, 3.4%, and 84.8%, respectively. The proportions of women with a visit within 3 weeks of delivery discharge were 28.5%, 26.4%, and 16.0% for hypertensive disorders of pregnancy, chronic, and no documented hypertension, respectively; by 12 weeks, the proportions increased to 62.4%, 64.5%, and 54.2%, respectively. Kaplan-Meier analyses indicated significant differences in utilization by hypertension type and interaction between hypertension type, and time before and after 6 weeks. In adjusted Cox proportional hazards models, the utilization rate before 6 weeks among women with hypertensive disorders of pregnancy was 1.42 times the rate for women with no documented hypertension (adjusted hazard ratio, 1.42; 95% confidence interval, 1.39-1.45). Women with chronic hypertension also had higher utilization rates compared to women with no documented hypertension before 6 weeks (adjusted hazard ratio, 1.28; 95% confidence interval, 1.24-1.33). Only chronic hypertension was significantly associated with utilization compared to the no documented hypertension group after 6 weeks (adjusted hazard ratio, 1.09; 95% confidence interval, 1.03-1.14). CONCLUSION In the 6 weeks following delivery discharge, women with hypertensive disorders of pregnancy and chronic hypertension attended outpatient postpartum care visits sooner than women with no documented hypertension. However, after 6 weeks this difference extended only to women with chronic hypertension. Overall, postpartum care utilization remained around 50% to 60% by 12 weeks in all groups. Addressing barriers to postpartum care attendance can ensure timely care for women at high risk for cardiovascular disease.
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Affiliation(s)
- Jasmine Ko Aqua
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (Ms Aqua)
| | - Nicole D Ford
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado); Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA (Dr Ford)
| | - Lisa M Pollack
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado)
| | - Jun Soo Lee
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado)
| | - Elena V Kuklina
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado)
| | - Donald K Hayes
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado)
| | - Adam S Vaughan
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado).
| | - Fátima Coronado
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado)
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Khraishah H, Daher R, Garelnabi M, Karere G, Welty FK. Sex, Racial, and Ethnic Disparities in Acute Coronary Syndrome: Novel Risk Factors and Recommendations for Earlier Diagnosis to Improve Outcomes. Arterioscler Thromb Vasc Biol 2023; 43:1369-1383. [PMID: 37381984 PMCID: PMC10664176 DOI: 10.1161/atvbaha.123.319370] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/09/2023] [Indexed: 06/30/2023]
Abstract
In this review, sex, racial, and ethnic differences in acute coronary syndromes on a global scale are summarized. The relationship between disparities in presentation and management of acute coronary syndromes and effect on worse clinical outcomes in acute coronary syndromes are discussed. The effect of demographic, geographic, racial, and ethnic factors on acute coronary syndrome care disparities are reviewed. Differences in risk factors including systemic inflammatory disorders and pregnancy-related factors and the pathophysiology underlying them are discussed. Finally, breast arterial calcification and coronary calcium scoring are discussed as methods to detect subclinical atherosclerosis and start early treatment in an attempt to prevent clinical disease.
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Affiliation(s)
- Haitham Khraishah
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore (H.K.)
| | - Ralph Daher
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos (R.D.)
| | - Mahdi Garelnabi
- Department of Biomedical and Nutritional Sciences and the UMass Lowell Center for Population Health, University of Massachusetts Lowell (M.G.)
| | - Genesio Karere
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC (G.K.)
| | - Francine K Welty
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (F.K.W.)
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Triebwasser JE, Lewey J, Walheim L, Sehdev HM, Srinivas SK. Electronic Reminder to Transition Care After Hypertensive Disorders of Pregnancy: A Randomized Controlled Trial. Obstet Gynecol 2023; 142:91-98. [PMID: 37294089 PMCID: PMC11180538 DOI: 10.1097/aog.0000000000005237] [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: 12/15/2022] [Accepted: 04/20/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Scalable interventions are needed to improve preventive care for those with increased cardiovascular disease (CVD) risk identified during pregnancy. We hypothesized that an automated reminder message for clinicians (nudge) would increase counseling at the postpartum visit on patient transitions of care. METHODS We conducted a single-center, randomized controlled trial including birthing people with a hypertensive disorder of pregnancy evaluating a nudge compared with usual care. The nudge, including counseling phrases and patient-specific information on hypertensive diagnosis, was sent to the obstetric clinician through the electronic medical record up to 7 days before the postpartum visit. The primary outcome was documentation of counseling on transitions of care to primary care or cardiology. Secondary outcomes were documentation of CVD risk, use of counseling phrases, and preventive care visit within 6 months. A sample size of 94 per group (n=188) was planned to compare the nudge intervention with usual care; given the anticipated loss to follow-up, the sample size was increased to 222. Intention-to-treat analyses were performed, with P <.05 considered significant. RESULTS From February to June 2021, 392 patients were screened, and 222 were randomized and analyzed. Of these, 205 (92.3%) attended a postpartum visit. Groups were similar, but more women in the usual care group had diabetes (16.1% vs 6.7%, P =.03). After adjustment for diabetes, patients in the nudge group were more likely to have documented counseling on transitions of care (38.8% vs 26.2%, adjusted relative risk [aRR] 1.53, 95% CI 1.02-2.31), CVD risk (21.4% vs 8.4%, aRR 2.57, 95% CI 1.20-5.49), and use of aspirin in a future pregnancy (14.3% vs 1.9%, aRR 7.49, 95% CI 1.66-33.93). Counseling phrases were used more often in the nudge group (11.2% vs 0.9%, aRR 12.27, 95% CI 1.50-100.28). Preventive care visit attendance did not differ by group (22.1% vs 24.6%, aRR 0.91, 95% CI 0.57-1.47). CONCLUSION A timely electronic reminder to obstetric clinicians improved counseling about transitions of care after hypertensive disorders of pregnancy but did not result in increased preventive care visit attendance. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT04660032.
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Affiliation(s)
- Jourdan E Triebwasser
- Divisions of Maternal-Fetal Medicine and Cardiology, University of Pennsylvania Perelman School of Medicine, and the Department of Obstetrics & Gynecology, Pennsylvania Hospital, Philadelphia, Pennsylvania; and the Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, Michigan
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25
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Steele DW, Adam GP, Saldanha IJ, Kanaan G, Zahradnik ML, Danilack-Fekete VA, Stuebe AM, Peahl AF, Chen KK, Balk EM. Postpartum Home Blood Pressure Monitoring: A Systematic Review. Obstet Gynecol 2023; Publish Ahead of Print:00006250-990000000-00798. [PMID: 37311173 DOI: 10.1097/aog.0000000000005270] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/11/2023] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To assess the effectiveness of postpartum home blood pressure (BP) monitoring compared with clinic-based follow-up and the comparative effectiveness of alternative home BP-monitoring regimens. DATA SOURCES Search of Medline, Cochrane, EMBASE, CINAHL, and ClinicalTrials.gov from inception to December 1, 2022, searching for home BP monitoring in postpartum individuals. METHODS OF STUDY SELECTION We included randomized controlled trials (RCTs), nonrandomized comparative studies, and single-arm studies that evaluated the effects of postpartum home BP monitoring (up to 1 year), with or without telemonitoring, on postpartum maternal and infant outcomes, health care utilization, and harm outcomes. After double screening, we extracted demographics and outcomes to SRDR+. TABULATION, INTEGRATION, AND RESULTS Thirteen studies (three RCTs, two nonrandomized comparative studies, and eight single-arm studies) met eligibility criteria. All comparative studies enrolled participants with a diagnosis of hypertensive disorders of pregnancy. One RCT compared home BP monitoring with bidirectional text messaging with scheduled clinic-based BP visits, finding an increased likelihood that at least one BP measurement was ascertained during the first 10 days postpartum for participants in the home BP-monitoring arm (relative risk 2.11, 95% CI 1.68-2.65). One nonrandomized comparative study reported a similar effect (adjusted relative risk [aRR] 1.59, 95% CI 1.36-1.77). Home BP monitoring was not associated with the rate of BP treatment initiation (aRR 1.03, 95% CI 0.74-1.44) but was associated with reduced unplanned hypertension-related hospital admissions (aRR 0.12, 95% CI 0.01-0.96). Most patients (83.3-87.0%) were satisfied with management related to home BP monitoring. Home BP monitoring, compared with office-based follow-up, was associated with reduced racial disparities in BP ascertainment by approximately 50%. CONCLUSION Home BP monitoring likely improves ascertainment of BP, which is necessary for early recognition of hypertension in postpartum individuals, and may compensate for racial disparities in office-based follow-up. There is insufficient evidence to conclude that home BP monitoring reduces severe maternal morbidity or mortality or reduces racial disparities in clinical outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022313075.
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Affiliation(s)
- Dale W Steele
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, and the Department of Epidemiology, Brown University School of Public Health, and the Department of Emergency Medicine, the Department of Pediatrics, and Department of Medicine, and the Department of Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island; the Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; the Center for Outcomes Research and Evaluation, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Cameron NA, Everitt IK, Lee KA, Yee LM, Khan SS. Chronic Hypertension in Pregnancy: A Lens Into Cardiovascular Disease Risk and Prevention. Hypertension 2023; 80:1162-1170. [PMID: 36960717 PMCID: PMC10192076 DOI: 10.1161/hypertensionaha.122.19317] [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: 03/25/2023]
Abstract
Hypertension is a major, modifiable risk factor for cardiovascular disease (CVD) in the United States. Over the past decade, the prevalence of chronic hypertension (CHTN) during pregnancy has nearly doubled with persistent race- and place-based disparities. Blood pressure elevations are of particular concern during pregnancy given higher risk of maternal and fetal morbidity and mortality, as well as higher lifetime risk of CVD in birthing individuals with CHTN. When identified during pregnancy, CHTN can, therefore, serve as a lens into CVD risk, as well as a modifiable target to mitigate cardiovascular risk throughout the life course. Health services and public health interventions that equitably promote cardiovascular health during the peripartum period could have an important impact on preventing CHTN and reducing lifetime risk of CVD. This review will summarize the epidemiology and guidelines for the diagnosis and management of CHTN in pregnancy; describe the current evidence for associations between CHTN, adverse pregnancy outcomes, and CVD; and identify opportunities for peripartum care to equitably reduce hypertension and CVD risk throughout the life course.
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Affiliation(s)
- Natalie A Cameron
- Department of Medicine, Division of General Internal Medicine (N.A.C.), Northwestern University Feinberg School of Medicine
| | - Ian K Everitt
- Department of Medicine, Division of Hospital Medicine (I.K.E.), Northwestern University Feinberg School of Medicine
| | - Kristen A Lee
- Department of Medicine, McGaw Medical Center of Northwestern University (K.A.L.)
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (L.M.Y.), Northwestern University Feinberg School of Medicine
| | - Sadiya S Khan
- Department of Medicine, Division of Cardiology (S.S.K.), Northwestern University Feinberg School of Medicine
- Department of Preventive Medicine (S.S.K.), Northwestern University Feinberg School of Medicine
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Hauspurg A, Seely EW, Rich-Edwards J, Hayduchok C, Bryan S, Roche AT, Jeyabalan A, Davis EM, Hart R, Shirriel J, Catov J. Postpartum home blood pressure monitoring and lifestyle intervention in overweight and obese individuals the first year after gestational hypertension or pre-eclampsia: A pilot feasibility trial. BJOG 2023; 130:715-726. [PMID: 36655365 PMCID: PMC10880812 DOI: 10.1111/1471-0528.17381] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/30/2022] [Accepted: 10/30/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To test the feasibility of a randomised trial of home blood pressure monitoring paired with a remote lifestyle intervention (Heart Health 4 New Moms) versus home blood pressure monitoring alone versus control in individuals with a hypertensive disorder of pregnancy in the first year postpartum. DESIGN Single-blinded three-arm randomised clinical trial. SETTING Two tertiary care hospitals and a community organisation. POPULATION Postpartum overweight and obese individuals with a hypertensive disorder of pregnancy and without pre-pregnancy hypertension or diabetes. METHODS We assessed the feasibility of recruitment and retention of 150 participants to study completion at 1-year postpartum with randomisation 1:1:1 into each arm. Secondary aims were to test effects of the interventions on weight, blood pressure and self-efficacy. RESULTS Over 23 months, we enrolled 148 of 400 eligible, screened individuals (37%); 28% black or other race and mean pre-pregnancy body mass index (BMI) of 33.4 ± 6.7 kg/m2 . In total, 129 (87%) participants completed the 1-year postpartum study visit. Overall, 22% of participants developed stage 2 hypertension (≥140/90 mmHg or on anti-hypertensive medications) by 1 year postpartum. There were no differences in weight or self-efficacy across the study arms. CONCLUSION In this pilot, randomised trial, we demonstrate feasibility of HBPM paired with a lifestyle intervention in the first year postpartum. We detected high rates of ongoing hypertension, emphasising the need for the development of effective interventions in this population.
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Affiliation(s)
- Alisse Hauspurg
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ellen W. Seely
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Janet Rich-Edwards
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Christina Hayduchok
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samantha Bryan
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrea T. Roche
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Arun Jeyabalan
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Esa M. Davis
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Renee Hart
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Janet Catov
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Avorgbedor F, McCoy TP, Gondwe KW, Xu H, Spielfogel E, Cortés YI, Vilme H, Lacey JVJ. Cardiovascular Disease-Related Emergency Department Visits and Hospitalization among Women with Hypertensive Disorders of Pregnancy. Am J Prev Med 2023; 64:686-694. [PMID: 36863895 PMCID: PMC11421440 DOI: 10.1016/j.amepre.2023.01.004] [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] [Received: 05/24/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION The risk of developing cardiovascular disease is higher for women who had hypertensive disorders of pregnancy than for women without a history of hypertensive disorders of pregnancy. However, it is unknown whether the emergency department visits and hospitalization differ between women with a history of hypertensive disorders of pregnancy and women without hypertensive disorders of pregnancy. The objective of this study was to characterize and compare cardiovascular disease-related emergency department visits, hospitalization rates, and diagnoses in women with a history of hypertensive disorders of pregnancy with those in women without. METHODS This study included participants from the California Teachers Study (N=58,718) with a history of pregnancy and data from 1995 through 2020. Incidence of cardiovascular disease-related emergency department visits and hospitalizations based on linkages with hospital records were modeled using multivariable negative binomial regression. Data were analyzed in 2022. RESULTS A total of 5% of the women had a history of hypertensive disorders of pregnancy (5.4%, 95% CI=5.2%, 5.6). A total of 31% of women had 1 or more cardiovascular disease-related emergency department visits (30.9%), and 30.1% had 1 or more hospitalizations. The incidence of cardiovascular disease-related emergency department visits (adjusted incident rate ratio=8.96, p<0.001) and hospitalizations (adjusted incident rate ratio=8.88, p<0.001) were significantly higher for women with hypertensive disorders of pregnancy than for those without, adjusting for other related characteristics of the women. CONCLUSIONS History of hypertensive disorders of pregnancy is associated with higher cardiovascular disease-related emergency department visits and hospitalizations. These findings underscore the potential burden on women and the healthcare system of managing complications associated with hypertensive disorders of pregnancy. Evaluating and managing cardiovascular disease risk factors in women with a history of hypertensive disorders of pregnancy is necessary to avoid cardiovascular disease-related emergency department visits and hospitalizations in this group.
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Affiliation(s)
- Forgive Avorgbedor
- School of Nursing, University of North Carolina Greensboro, Greensboro, North Carolina.
| | - Thomas P McCoy
- School of Nursing, University of North Carolina Greensboro, Greensboro, North Carolina
| | - Kaboni W Gondwe
- School of Nursing, University of Wisconsin Milwaukee, Milwaukee, Wisconsin
| | - Hanzhang Xu
- Duke Family Medicine & Community Health, Duke University Medical Center, Durham, North Carolina
| | | | - Yamnia I Cortés
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Helene Vilme
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
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Burgess A, Stover S. Improving Cardiovascular Follow-Up after Diagnosis of a Hypertensive Disorder of Pregnancy using the Electronic Health Record. MCN Am J Matern Child Nurs 2023; 48:127-133. [PMID: 36744856 DOI: 10.1097/nmc.0000000000000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death among women. Sex-specific risk factors for cardiovascular disease include history of a hypertensive disorder of pregnancy. PROBLEM After diagnosis of a hypertensive disorder of pregnancy, professional societies recommend follow-up with a primary care provider for preventative care. There are gaps in patient and health care provider knowledge of the association between a hypertensive disorder of pregnancy and cardiovascular disease. That gap has a negative effect on patients receiving recommended follow-up. METHODS An electronic registry was created to identify those who gave birth in our health system and had a diagnosis of hypertensive disorder of pregnancy. From this, information outreach was sent electronically to the patient and their primary care provider. INTERVENTIONS Communication in the outreach included education on the association between hypertensive disorders of pregnancy and cardiovascular disease, the importance of follow-up, cardiopreventative strategies, and biochemical assessment. Medical records were audited at approximately 6 months postpartum to determine if patients completed a visit with their primary care provider to discuss cardiovascular risks. RESULTS Between May 2021 and June 2022, 15% ( n = 1,131) of patients who gave birth in our health system had a diagnosis of hypertensive disorder of pregnancy. Ninety percent of those patients who received outreach communication viewed the letter. At baseline, 16% of patients during postpartum with a hypertensive disorder of pregnancy saw their primary care provider to discuss cardiopreventative strategies. After implementation of our program, 26% of those with a hypertensive disorder of pregnancy saw their primary care provider for follow-up and discussed cardiopreventative strategies. CLINICAL IMPLICATIONS Nurses should ensure that women during postpartum and their primary care providers are educated about the association of hypertensive disorders of pregnancy and long-term cardiovascular risk. The electronic health record may be an optimal way to ensure education is provided and follow-up scheduled.
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Dubrofsky L, Gundy S, Boesch L, Poolman K, Nerenberg KA, Tobe S. Patient perspectives on a pilot virtual follow-up program after hypertensive disorders of pregnancy: a qualitative study. CJC Open 2023. [DOI: 10.1016/j.cjco.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
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Rayes B, Ardissino M, Slob EAW, Patel KHK, Girling J, Ng FS. Association of Hypertensive Disorders of Pregnancy With Future Cardiovascular Disease. JAMA Netw Open 2023; 6:e230034. [PMID: 36800181 PMCID: PMC9938428 DOI: 10.1001/jamanetworkopen.2023.0034] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/02/2023] [Indexed: 02/18/2023] Open
Abstract
Conclusions and Relevance The findings of this study provide genetic evidence supporting an association between HDPs and higher risk of coronary artery disease and stroke, which is only partially mediated by cardiometabolic factors. This supports classification of HDPs as risk factors for cardiovascular disease. Design, Setting, and Participants A genome-wide genetic association study using mendelian randomization (MR) was performed from February 16 to March 4, 2022. Primary analysis was conducted using inverse-variance-weighted MR. Mediation analyses were performed using a multivariable MR framework. All studies included patients predominantly of European ancestry. Female-specific summary-level data from FinnGen (sixth release). Exposures Uncorrelated (r2<0.001) single-nucleotide variants (SNVs) were selected as instrumental variants from the FinnGen consortium summary statistics for exposures of any HDP, gestational hypertension, and preeclampsia or eclampsia. Importance Hypertensive disorders in pregnancy (HDPs) are major causes of maternal and fetal morbidity and are observationally associated with future maternal risk of cardiovascular disease. However, observational results may be subject to residual confounding and bias. Main Outcomes and Measures Genetic association estimates for outcomes were extracted from genome-wide association studies of 122 733 cases for coronary artery disease, 34 217 cases for ischemic stroke, 47 309 cases for heart failure, and 60 620 cases for atrial fibrillation. Objective To investigate the association of HDPs with multiple cardiovascular diseases. Results Genetically predicted HDPs were associated with a higher risk of coronary artery disease (odds ratio [OR], 1.24; 95% CI, 1.08-1.43; P = .002); this association was evident for both gestational hypertension (OR, 1.08; 95% CI, 1.00-1.17; P = .04) and preeclampsia/eclampsia (OR, 1.06; 95% CI, 1.01-1.12; P = .03). Genetically predicted HDPs were also associated with a higher risk of ischemic stroke (OR, 1.27; 95% CI, 1.12-1.44; P = 2.87 × 10-4). Mediation analysis revealed a partial attenuation of the effect of HDPs on coronary artery disease after adjustment for systolic blood pressure (total effect OR, 1.24; direct effect OR, 1.10; 95% CI, 1.02-1.08; P = .02) and type 2 diabetes (total effect OR, 1.24; direct effect OR, 1.16; 95% CI, 1.04-1.29; P = .008). No associations were noted between genetically predicted HDPs and heart failure (OR, 0.97; 95% CI, 0.76-1.23; P = .79) or atrial fibrillation (OR, 1.11; 95% CI, 0.65-1.88; P = .71).
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Affiliation(s)
- Bilal Rayes
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Maddalena Ardissino
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Eric A. W. Slob
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
- Department of Applied Economics, Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Erasmus University Rotterdam Institute for Behavior and Biology, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | - Joanna Girling
- Department of Obstetrics and Gynaecology, Chelsea and Westminster National Health Service Trust, London, United Kingdom
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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D'Amico R, Dalmacy D, Akinduro JA, Hyer M, Thung S, Mao S, Fareed N, Bose-Brill S. Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes. JAMA Netw Open 2023; 6:e2254765. [PMID: 36745454 DOI: 10.1001/jamanetworkopen.2022.54765] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
IMPORTANCE Gestational diabetes (GD) affects up to 10% of pregnancies and increases lifetime risk of type 2 diabetes 10-fold; postpartum diabetes evaluation and primary care follow-up are critical in preventing and detecting type 2 diabetes. Despite clinical guidelines recommending universal follow-up, little remains known about how often individuals with GD access primary care and type 2 diabetes screening. OBJECTIVE To describe patterns of primary care follow-up and diabetes-related care among individuals with and without GD in the first year post partum. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a private insurance claims database to compare follow-up in the first year post partum between individuals with GD, type 2 diabetes, and no diabetes diagnosis. Participants included postpartum individuals aged 15 to 51 years who delivered between 2015 and 2018 and had continuous enrollment from 180 days before to 366 days after the delivery date. Data were analyzed September through October 2021 and reanalyzed November 2022. MAIN OUTCOMES AND MEASURES Primary care follow-up visits and diabetes-related care (blood glucose testing and diabetes-associated visit diagnoses) were determined by evaluation and management, Current Procedural Terminology, and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, respectively. RESULTS A total of 280 131 individuals were identified between 2015 and 2018 (mean age: 31 years; 95% CI, 27-34 years); 12 242 (4.4%) had preexisting type 2 diabetes and 18 432 (6.6%) had GD. A total of 50.9% (95% CI, 49.9%-52.0%) of individuals with GD had primary care follow-up, compared with 67.2% (95% CI, 66.2%-68.2%) of individuals with preexisting type 2 diabetes. A total of 36.2% (95% CI, 35.1%-37.4%) of individuals with GD had diabetes-related care compared with 56.9% (95% CI, 55.7%-58.0%) of individuals with preexisting diabetes. Only 36.0% (95% CI, 34.4%-37.6%) of individuals with GD connected with primary care received clinical guideline concordant care with blood glucose testing 12 weeks post partum. CONCLUSIONS AND RELEVANCE In this cohort study of postpartum individuals, individuals with GD had lower rates of primary care and diabetes-related care compared with those with preexisting type 2 diabetes, and only 36% of those with GD received guideline-recommended blood glucose testing in the first 12 weeks post partum. This illustrates a missed opportunity for early intervention in diabetes surveillance and prevention and demonstrates the need to develop a multidisciplinary approach for postpartum follow-up.
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Affiliation(s)
- Rachel D'Amico
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Djhenne Dalmacy
- Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Jenifer A Akinduro
- Department of Obstetrics and Gynecology, Indiana University, Bloomington
| | - Madison Hyer
- Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Stephen Thung
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
| | - Shengyi Mao
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Naleef Fareed
- Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
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Scholz AS, Hassdenteufel K, Gutsfeld R, Müller M, Goetz M, Bauer A, Wallwiener M, Brucker SY, Joos S, Colombo MG, Hawighorst-Knapstein S, Chaudhuri A, Beck F, Wallwiener S. Observational database study on preeclampsia and postpartum medical care up to 7.5 years after birth. Sci Rep 2022; 12:21230. [PMID: 36482054 PMCID: PMC9732277 DOI: 10.1038/s41598-022-25596-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022] Open
Abstract
Preeclampsia is associated with a substantially increased long-term risk for cardiovascular, cerebrovascular and renal disease. It remains unclear whether and to which extent specialized medical postpartum care is sought. We aimed to assess current utilization of postpartum primary and specialized care and medication prescription behavior in women who experienced preeclampsia. This retrospective observational study based on statutory claims data included 193,205 women with 258,344 singleton live births between 2010 and 2017 in Southern Germany. Postpartum care was evaluated by analyzing and comparing the frequency of medical consultations in primary and specialized care and prescriptions for antihypertensive medication among women with and without preeclampsia up to 7.5 years after delivery. Gynecologists and general practitioners were the main health care providers for all women. Although specialized postpartum care was sought by more women after preeclampsia, the effect size indices revealed no considerable association between a history of preeclampsia and the utilization of specialized outpatient aftercare (e.g. 2% vs. 0.6% of patients with and without preeclampsia who consulted a nephrologist during the first year postpartum, r = 0.042). Preeclampsia was associated with an increased risk to take any antihypertensive medication after delivery (HR 2.7 [2.6; 2.8]). Postpartum referral to specialized outpatient care and quarterly prescriptions of antihypertensives following preeclampsia failed to match the early and rapidly increased incidence and risk of hypertension. These data highlight the missed opportunity to implement a reasonable follow-up strategy and prevention management in order to achieve long-term clinical benefits.
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Affiliation(s)
- Anna S Scholz
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
| | - Kathrin Hassdenteufel
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Raphael Gutsfeld
- Department of Psychology, Ludwig Maximilian University, Munich, Germany
| | - Mitho Müller
- Department of Psychology, Ludwig Maximilian University, Munich, Germany
| | - Maren Goetz
- Department of General Pediatrics, University Children's Hospital, Heidelberg, Germany
| | - Armin Bauer
- Department of Women's Health, University Hospital Tuebingen, Tuebingen, Germany
| | - Markus Wallwiener
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Sara Y Brucker
- Department of Women's Health, University Hospital Tuebingen, Tuebingen, Germany
| | - Stefanie Joos
- Institute for General Practice and Interprofessional Care, University Hospital Tuebingen, Tuebingen, Germany
| | - Miriam Giovanna Colombo
- Institute for General Practice and Interprofessional Care, University Hospital Tuebingen, Tuebingen, Germany
| | | | - Ariane Chaudhuri
- Department of Health Promotion, AOK Baden-Wuerttemberg, Stuttgart, Germany
| | - Frauke Beck
- Department of Health Promotion, AOK Baden-Wuerttemberg, Stuttgart, Germany
| | - Stephanie Wallwiener
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
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Countouris M, Jaramillo Restrepo V, Bidani S, Catov J, Berlacher K, Jeyabalan A, Hauspurg A. Feasibility of Utilizing Telehealth in a Multidisciplinary Postpartum Hypertension Clinic. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2022; 3:877-886. [PMID: 36479373 PMCID: PMC9712043 DOI: 10.1089/whr.2022.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/07/2022]
Abstract
Introduction Remote delivery of care improves outcomes following hypertensive disorders of pregnancy, but little is known about the implementation of a multidisciplinary clinic in the virtual space. In this study, we developed a multidisciplinary postpartum hypertension clinic with a telehealth component run jointly with Maternal-Fetal Medicine and Cardiology. Materials and Methods Women were referred from Cardiology and Obstetrics providers or through our postpartum remote blood pressure (BP) program and were offered the option of an in-person or telemedicine visit. For virtual visits, BP was recorded by home measurement. We compared clinical and demographic characteristics by visit type (virtual vs. in-person). Results Of 175 patients scheduled (2019-2021), 140 attended visits (80% show rate) a mean of 11 weeks postpartum, with 92 (65.7%) seen virtually and 48 (34.2%) seen in-person. Clinical and demographic factors, including self-reported race and insurance type, did not differ between women seen virtually versus in-person. Overall, 97 (69.3%) of women were still on antihypertensive agents at the time of their visit with 33 (34.0%) on more than one antihypertensive agent, which did not differ by visit type. Women who were seen virtually lived a farther distance from the clinic (median 11.6 [interquartile range; IQR 7.7, 30.8] vs. median 7.9 [IQR 5.8, 21.1] miles; p = 0.02). Conclusions Implementation of a multidisciplinary postpartum hypertension clinic in the virtual space is feasible, targets women at high risk for persistently elevated postpartum BP, and maintains equal attendance compared with in-person visits. Virtual visits deliver care equitably across different racial and socioeconomic groups and may improve access to care in rural areas.
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Affiliation(s)
- Malamo Countouris
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Address correspondence to: Malamo Countouris, MD, MS, Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| | | | - Shruti Bidani
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Janet Catov
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kathryn Berlacher
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arun Jeyabalan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Gemkow JW, Liss DT, Yang TY, Padilla R, King PL, Pereyra S, Cox-Batson S, Tenfelde S, Masinter L. Predicting Postpartum Transition to Primary Care in Community Health Centers. Am J Prev Med 2022; 63:689-699. [PMID: 35840450 DOI: 10.1016/j.amepre.2022.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Although the transition to primary care after routine postpartum care has been recommended to mitigate adverse maternal outcomes, little is known about real-world transition patterns. The objective of this study was to describe the patterns and predictors of transition in a postpartum cohort receiving care at federally qualified health centers and a subcohort of clinically high-risk patients. METHODS Electronic health record data collected between 2017 and 2019 were analyzed in 2021 for unadjusted analyses and multivariable regression models for both the full and high-risk cohorts. The primary outcome was completion of a primary care visit within 6 months of delivery. Primary predictors in both cohorts were insurance loss, postpartum visit, first-trimester visit, and medical visit within the year prepregnancy; for the full cohort, high-risk status was also studied. RESULTS The full cohort (N=7,926) analysis showed that 17.3% completed a primary care visit. In unadjusted and adjusted analysis, all 5 predictors were significantly associated with primary care visit completion; 25.0% of high-risk patients completed a primary care visit, and patients who lost insurance had 66% lower odds of primary care visit completion (95% CI=0.24, 0.48). In unadjusted and adjusted analysis for the high-risk cohort (n=1,956, 24.7% of full cohort), all predictors except postpartum visit were significantly associated with primary care visit completion. CONCLUSIONS Postpartum patients at federally qualified health centers transitioned to primary care at low rates; insurance loss was one significant barrier to care. Strategies to increase continuity, including improving insurance access, should be studied. Future research is needed to study structural inequity, the impact of primary care on maternal outcomes, and patient experience.
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Affiliation(s)
| | - David T Liss
- Health Research and Education Team, AllianceChicago, Chicago, Illinois; Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ta-Yun Yang
- Health Research and Education Team, AllianceChicago, Chicago, Illinois
| | - Roxane Padilla
- Health Research and Education Team, AllianceChicago, Chicago, Illinois
| | | | | | | | - Sandi Tenfelde
- Near North Health Service Corporation, Chicago, Illinois; Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, Illinois
| | - Lisa Masinter
- Health Research and Education Team, AllianceChicago, Chicago, Illinois
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Teoule J, Woll C, Sütterlin M, Filsinger B. Versorgungsrealität von Frauen nach hypertensiver
Schwangerschaftserkrankung – eine monozentrische fragebogenbasierte
Analyse. Z Geburtshilfe Neonatol 2022; 227:127-133. [PMID: 36302547 DOI: 10.1055/a-1956-4358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Zusammenfassung
Einleitung Frauen nach einer hypertensiven Schwangerschaftserkrankung wird
aufgrund ihres signifikant erhöhten kardiovaskulären Risikos zu
Screeninguntersuchungen und primärer Prävention geraten. Diese
Studie soll einen Beitrag zur Ermittlung der aktuellen Nachsorgepraxis leisten
und aufzeigen, wie viele Frauen an den empfohlenen Nachsorgeuntersuchungen mit
Beratung zur Reduktion von Risikofaktoren teilnehmen.
Material und Methoden Monozentrische Patientinnenbefragung von 113 Frauen,
welche im Zeitraum von 2014 bis 2019 von einer hypertensiven
Schwangerschaftserkrankung betroffen waren. Es erfolgte eine deskriptive
statistische Auswertung.
Ergebnisse Eine Nachsorgeuntersuchung erfolgte bei 54% der Frauen.
Es wurden 47% der Patientinnen im persönlichen Gespräch
über ihre Erkrankung informiert und auf mögliche langfristige
gesundheitliche Konsequenzen hingewiesen. Von 67 übergewichtigen Frauen
(BMI≥25 kg/m2) erhielten 23% eine
Empfehlung zur Steigerung der körperlichen Aktivität und
13% wurde zur Gewichtsreduktion geraten. Es stellten sich signifikant
mehr Frauen mit höherer Krankheitslast (BMI, p=0,027;
arterieller Hypertonus, p=0,016) und gravierender Ausprägung der
Erkrankung (Eklampsie, Aufenthalt auf einer Intensivstation, jeweils
p=0,049) zu weiteren Untersuchungen vor.
Schlussfolgerung Die vorliegenden Ergebnisse legen nahe, dass die
Maßnahmen zur Prävention und Früherkennung von
kardiovaskulären Erkrankungen in unserem Patientinnenkollektiv nicht
ausgeschöpft wurden. Unabhängig des Ausprägungsgrades
der Erkrankung sollten alle Frauen eine Empfehlung zur Teilnahme an
Nachsorgeuntersuchung erhalten.
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Affiliation(s)
- Julia Teoule
- Frauenklinik, Ruprecht-Karls-Universität Heidelberg
Medizinische Fakultät Mannheim, Mannheim, Germany
| | - Christian Woll
- Psychologie, Ludwigs-Maximilians-Universität München,
Lehr- und Forschungseinheit Klinische Psychologie des Kindes- und Jugendalters,
München, Germany
| | - Marc Sütterlin
- Frauenklinik, Ruprecht-Karls-Universität Heidelberg
Medizinische Fakultät Mannheim, Mannheim, Germany
| | - Barbara Filsinger
- Frauenklinik, Ruprecht-Karls-Universität Heidelberg
Medizinische Fakultät Mannheim, Mannheim, Germany
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Telemedicine may increase visit completion rates in postpartum patients with preeclampsia. PLoS One 2022; 17:e0275741. [PMID: 36269782 PMCID: PMC9586337 DOI: 10.1371/journal.pone.0275741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 09/22/2022] [Indexed: 11/05/2022] Open
Abstract
Postpartum cardiovascular (CV) evaluation of women with preeclampsia is recommended to screen for and treat modifiable risk factors to reduce lifetime CV risk. However, attendance at in-person postpartum obstetric and cardiology clinic visits is low. The aim of this study was to compare the completion rate of new patient telemedicine visits to in-person office visits for patients with preeclampsia referred for postpartum hypertension management and CV risk assessment at a single center. There were 236 unique new patient visits scheduled during the study period. The average age was 30.3 years, 73.7% patients were Black, and 56.7% had Medicaid insurance. The completion rate was 32% for in-person clinic visits and 70% for telemedicine visits. Women who did not complete an office visit were more likely to be Black (87% vs. 56%, p < 0.01) and younger (29.1 vs. 31.4 years, p = 0.04) compared to those who completed a visit. Notably, this difference was not seen with telemedicine visits. Telemedicine may provide a novel opportunity to improve the care for blood pressure management and CV risk reduction in a vulnerable population at risk of premature CV disease.
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Cameron NA, Bello NA, Khan SS. Bringing the Cuff Home: Challenges and Opportunities Associated With Home Blood Pressure Monitoring Among Reproductive-Aged Individuals. Am J Hypertens 2022; 35:688-690. [PMID: 35695260 PMCID: PMC9340642 DOI: 10.1093/ajh/hpac074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/09/2022] [Indexed: 02/01/2023] Open
Affiliation(s)
- Natalie A Cameron
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine, Chicago, Illinois, USA
| | - Natalie A Bello
- Smidt Heart Institute, Cedars Sinai Medical Center, Department of Cardiology, Chicago, Illinois, USA
| | - Sadiya S Khan
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Chicago, Illinois, USA
- Northwestern University Feinberg School of Medicine, Department of Preventive Medicine, Chicago, Illinois, USA
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Gregory EF, Passarella M, Levine LD, Lorch SA. Interconception Preventive Care and Recurrence of Pregnancy Complications for Medicaid-Insured Women. J Womens Health (Larchmt) 2022; 31:826-833. [PMID: 35231191 PMCID: PMC9245725 DOI: 10.1089/jwh.2021.0355] [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
Background: Pregnancy complications may recur and are associated with potentially modifiable risks. The role of interconception preventive care in reducing repeat pregnancy complications is understudied. Materials and Methods: This retrospective cohort used 2007-2012 Medicaid claims from 12 states. Included women who had an index birth complicated by prematurity, hypertension, or diabetes, a subsequent birth within 36 months, and Medicaid eligibility for ≥11 of 12 months after index birth. Logistic regression assessed for an association between the exposure of preventive visits in the year after index birth and primary outcomes of prematurity, hypertension, or diabetes in the subsequent pregnancy. Regression adjusted for confounders including demographics (age, race and ethnicity, rural residence, state), index pregnancy features (complications, prenatal visits, multiple gestation, maternal and infant length of stay, year), visits to address complications in the index birth, and interpregnancy interval. Results: Of 17,372 women, mean age was 24.3 ± 5.3 years, and race/ethnicity was 50.3% non-Hispanic White, 27.2% non-Hispanic Black, and 11.9% Hispanic. In the index pregnancy 43.3% experienced prematurity, 39.2% experienced hypertension, and 34.2% experienced diabetes. In the year after the index pregnancy, 54.7% had at least one preventive visit. In the second pregnancy, 47.7% experienced prematurity, hypertension, or diabetes. Recurrence rates were 28.1% for preterm birth, 38.0% for hypertension, and 48.3% for diabetes. Preventive visits were associated with reduced hypertension in the subsequent pregnancy (OR 0.88, 95% CI 0.82-0.97) but not reduced preterm birth or diabetes. Conclusions: Preventive visits after an index birth complicated by prematurity, hypertension, or diabetes were associated with 10% lower odds of hypertension in a subsequent pregnancy, but not with reductions in diabetes or prematurity. Some complications may be more amenable to interconception preventive services than others.
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Affiliation(s)
- Emily F. Gregory
- Division of General Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Molly Passarella
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lisa D. Levine
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott A. Lorch
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Attanasio LB, Ranchoff BL, Cooper MI, Geissler KH. Postpartum Visit Attendance in the United States: A Systematic Review. Womens Health Issues 2022; 32:369-375. [PMID: 35304034 DOI: 10.1016/j.whi.2022.02.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 01/31/2022] [Accepted: 02/04/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Adequate postpartum care, including the comprehensive postpartum visit, is critical for long-term maternal health and the reduction of maternal mortality, particularly for people who may lose insurance coverage postpartum. However, variation in previous estimates of postpartum visit attendance in the United States makes it difficult to assess rates of attendance and associated characteristics. METHODS We conducted a systematic review of estimates of postpartum visit attendance. We searched PubMed, CINAHL, PsycInfo, and Web of Science for articles published in English from 1995 to 2020 using search terms to capture postpartum visit attendance and use in the United States. RESULTS Eighty-eight studies were included in this analysis. Postpartum visit attendance rates varied substantially, from 24.9% to 96.5%, with a mean of 72.1%. Postpartum visit attendance rates were higher in studies using patient self-report than those using administrative data. The number of articles including an estimate of postpartum visit attendance increased considerably over the study period; the majority were published in 2015 or later. CONCLUSIONS Our findings suggest that increased systematic data collection efforts aligned with postpartum care guidelines and attention to postpartum visit attendance rates may help to target policies to improve maternal wellbeing. Most estimates indicate that a substantial proportion of women do not attend at least one postpartum visit, potentially contributing to maternal morbidity as well as preventing a smooth transition to future well-woman care. Estimates of current postpartum visit attendance are important for informing efforts that seek to increase postpartum visit attendance rates and to improve the quality of care.
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Affiliation(s)
- Laura B Attanasio
- Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts.
| | - Brittany L Ranchoff
- Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts
| | - Michael I Cooper
- Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts
| | - Kimberley H Geissler
- Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts
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Aldridge E, Pathirana M, Wittwer M, Sierp S, Leemaqz SY, Roberts CT, Dekker GA, Arstall MA. Prevalence of Metabolic Syndrome in Women After Maternal Complications of Pregnancy: An Observational Cohort Analysis. Front Cardiovasc Med 2022; 9:853851. [PMID: 35360031 PMCID: PMC8963931 DOI: 10.3389/fcvm.2022.853851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Certain complications of pregnancy, including hypertensive disorders of pregnancy, gestational diabetes mellitus, intrauterine growth restriction, spontaneous preterm birth, and placental abruption, are established independent risk factors for premature cardiovascular disease in women. Metabolic syndrome, which is associated with an increased risk of cardiovascular disease, may be a suitable alternative to traditional cardiovascular risk calculators that underestimate risk in young women. This study aimed to investigate the prevalence of metabolic syndrome in women who experienced a complicated pregnancy 6 months earlier. Methods This observational study investigated the prevalence of metabolic syndrome as defined by the International Diabetes Federation in all eligible participants (n = 247) attending a postpartum lifestyle intervention clinic from August 2018 to June 2021 at the Lyell McEwin Hospital in Adelaide, South Australia. Results A total of 89 (36%) participants met the criteria for metabolic syndrome at a mean follow up time of 7 months postpartum. Almost 90% of the cohort were abdominally obese, and over two thirds of the total cohort met at least two of the criteria for metabolic syndrome. Conclusions Women with a prior history of one of the common major pregnancy complications are at high risk of future cardiovascular and metabolic disease, with many showing either metabolic syndrome or multiple risk factors at only 7 months postpartum. The results indicate that follow-up within 1 year postpartum is an appropriate time to commence preventative strategies, as many women are already showing early signs of disease.
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Affiliation(s)
- Emily Aldridge
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
- Department of Cardiology, Northern Adelaide Local Health Network, Elizabeth Vale, SA, Australia
- *Correspondence: Emily Aldridge
| | - Maleesa Pathirana
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Melanie Wittwer
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Department of Cardiology, Northern Adelaide Local Health Network, Elizabeth Vale, SA, Australia
| | - Susan Sierp
- Department of Cardiology, Northern Adelaide Local Health Network, Elizabeth Vale, SA, Australia
| | - Shalem Y. Leemaqz
- Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
| | - Claire T. Roberts
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
| | - Gustaaf A. Dekker
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Department of Obstetrics & Gynecology, Northern Adelaide Local Health Network, Elizabeth Vale, SA, Australia
| | - Margaret A. Arstall
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Department of Cardiology, Northern Adelaide Local Health Network, Elizabeth Vale, SA, Australia
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42
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Suresh S, Amegashie C, Patel E, Nieman KM, Rana S. Racial Disparities in Diagnosis, Management, and Outcomes in Preeclampsia. Curr Hypertens Rep 2022; 24:87-93. [PMID: 35254590 DOI: 10.1007/s11906-022-01172-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE OF THE REVIEW Racial disparities are prevalent in many aspects of obstetric care in the USA. Non-Hispanic black women have a higher prevalence of the diagnosis of hypertensive disorders of pregnancy in addition to associated morbidity and mortality. The purpose of this review is to review current data regarding racial disparities in the diagnosis and management of hypertensive disorders of pregnancy. RECENT FINDINGS Diagnosis of hypertensive disorders of pregnancy is more common among non-Hispanic black women even after adjustment for comorbidities. Furthermore, prevalence of severe morbidity among those with hypertensive disorders of pregnancy is increased in non-Hispanic black women, including cardiovascular events related. Proposed management solutions include quality improvement initiatives, telehealth, and strategies to reduce both structural racism and implicit bias. Racial disparities exist in both diagnosis and management of hypertensive disorders of pregnancy; further innovative work is needed to reduce these disparities.
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Affiliation(s)
- Sunitha Suresh
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | | | - Easha Patel
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Kristin M Nieman
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Sarosh Rana
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA.
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43
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Primary Care-Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review. J Gen Intern Med 2022; 37:912-921. [PMID: 34993867 PMCID: PMC8734553 DOI: 10.1007/s11606-021-07149-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/08/2021] [Indexed: 12/20/2022]
Abstract
Several common adverse pregnancy outcomes can reveal subclinical or latent cardiovascular disease (CVD) risk, transiently exposed through the physiologic stress of pregnancy. The year after pregnancy may be a singular opportunity to identify and initiate treatment for CVD risk, even before the onset of traditional CVD risk factors. However, clinical guidance regarding CVD risk management after adverse pregnancy outcomes is lacking. We therefore conducted a systematic review of US clinical practice guidelines and professional society recommendations to inform primary care-based CVD risk management after adverse pregnancy outcomes. We identified 13 relevant publications. While most recommendations were based on limited or weak evidence, we identified several areas of consensus. First, individuals with an adverse pregnancy outcome associated with future CVD are likely to benefit from CVD risk assessment-accompanied by education, counseling, and support for lifestyle modification-beginning within the first postpartum year. Second, among clinicians, clear and consistent documentation about adverse pregnancy outcomes and recommended follow-up is important to coordinate care after pregnancy. In addition, patients need to be informed about their pregnancy complications and associated CVD risks, so that they can make informed health care and lifestyle decisions. Finally, in general, CVD prevention in the year after an adverse pregnancy outcome focuses on lifestyle modification, reserving pharmacotherapy for the highest-risk patients and those with traditional CVD risk factors. While postpartum lifestyle interventions show promise for reducing CVD risk after adverse pregnancy outcomes, continued research to determine the optimal content, timing, and long-term effects of such interventions is needed.
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44
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Focus on today's evidence while keeping an eye on the future: lessons derived from hypertension in women. J Hum Hypertens 2022; 36:882-886. [PMID: 35082377 DOI: 10.1038/s41371-021-00652-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 12/17/2022]
Abstract
While evidence-based medicine has contributed enormously to the uniformity and rationale of patient care, it is necessary that we anticipate changes in order to implement their rapid translation to practice. The purpose of this review is to expose three issues regarding cardiovascular health in women, including milestones to reflect the pace at which these are incorporated into public policies. Two of these matters, as changes in the thresholds of normal blood pressure in gestation and in nonpregnant women, need further evidence and deserve to be retrospectively analyzed in high-quality databases. The third subject derives from the association of remote cardiovascular complications of hypertensive pregnancies, an example of the unnecessary delay of more than two decades to install a wide prevention strategy when the health system is not on the watch.
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45
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Fraser A, Markovitz AR, Haug EB, Horn J, Romundstad PR, Dalen H, Rich-Edwards J, Åsvold BO. Ten-Year Cardiovascular Disease Risk Trajectories by Obstetric History: A Longitudinal Study in the Norwegian HUNT Study. J Am Heart Assoc 2022; 11:e021733. [PMID: 35014852 PMCID: PMC9238539 DOI: 10.1161/jaha.121.021733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Women with a history of obstetric complications are at increased risk of cardiovascular disease, but whether they should be specifically targeted for cardiovascular disease (CVD) risk screening is unknown. Methods and Results We used linked data from the Norwegian HUNT (Trøndelag Health) Study and the Medical Birth Registry of Norway to create a population‐based, prospective cohort of parous women. Using an established CVD risk prediction model (A Norwegian risk model for cardiovascular disease), we predicted 10‐year risk of CVD (nonfatal myocardial infarction, fatal coronary heart disease, and nonfatal or fatal stroke) based on established risk factors (age, systolic blood pressure, total and high‐density lipoprotein cholesterol, smoking, antihypertensive use, and family history of myocardial infarction). Predicted 10‐year CVD risk scores in women aged between 40 and 60 years were consistently higher in those with a history of obstetric complications. For example, when aged 40 years, women with a history of preeclampsia had a 0.06 percentage point higher mean risk score than women with all normotensive deliveries, and when aged 60 years this difference was 0.86. However, the differences in the proportion of women crossing established clinical thresholds for counseling and treatment in women with and without a complication were modest. Conclusions Findings do not support targeting parous women with a history of pregnancy complications for CVD screening. However, pregnancy complications identify women who would benefit from primordial and primary prevention efforts such as encouraging and supporting behavioral changes to reduce CVD risk in later life.
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Affiliation(s)
- Abigail Fraser
- Population Health Sciences Bristol Medical School University of Bristol Bristol UK.,Medical Research Council Integrative Epidemiology Unit at the University of Bristol Bristol UK
| | - Amanda R Markovitz
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA.,Division of Women's Health Brigham and Women's Hospital Boston MA.,Connors Center for Women's Health and Gender BiologyBrigham and Women's Hospital Boston MA.,Mathematica Cambridge MA
| | - Eirin B Haug
- Population Health Sciences Bristol Medical School University of Bristol Bristol UK.,Medical Research Council Integrative Epidemiology Unit at the University of Bristol Bristol UK.,K.G. Jebsen Center for Genetic Epidemiology Department of Public Health and Nursing NTNUNorwegian University of Science and Technology Trondheim Norway
| | - Julie Horn
- HUNT Research Center Department of Public Health and Nursing NTNUNorwegian University of Science and Technology Levanger Norway.,Department of Obstetrics and Gynecology Levanger HospitalNord-Trøndelag Hospital Trust Levanger Norway
| | - Pål Richard Romundstad
- Department of Public Health and Nursing NTNUNorwegian University of Science and Technology Trondheim Norway
| | - Håvard Dalen
- Department of Medicine Levanger HospitalNord-Trøndelag Hospital Trust Levanger Norway.,Department of Circulation and Medical Imaging NTNUNorwegian University of Science and Technology Trondheim Norway.,Cardiac Clinic St Olavs HospitalTrondheim University Hospital Trondheim Norway
| | - Janet Rich-Edwards
- Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA.,Division of Women's Health Brigham and Women's Hospital Boston MA.,Connors Center for Women's Health and Gender BiologyBrigham and Women's Hospital Boston MA
| | - Bjørn Olav Åsvold
- K.G. Jebsen Center for Genetic Epidemiology Department of Public Health and Nursing NTNUNorwegian University of Science and Technology Trondheim Norway.,HUNT Research Center Department of Public Health and Nursing NTNUNorwegian University of Science and Technology Levanger Norway.,Department of Endocrinology Clinic of Medicine St. Olavs HospitalTrondheim University HospitalNorwegian University of Science and TechnologyNorwegian University of Science and Technology Trondheim Norway
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Correia LL, Machado MMT, Araújo DABS, Gomes YVC, Pinheiro MSN, Rocha HAL, Nogueira DL, Sousa GDSD, Farias-Antuñez S, Castro MC. Primary Health Care during the COVID-19 pandemic in Fortaleza, Brazil: associated factors and pattern of use by mothers and children up to 18 months of age. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2022; 25:e220036. [DOI: 10.1590/1980-549720220036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022] Open
Abstract
ABSTRACT Objective: To analyze the delay or failure to seek primary health care by the mother-child dyads during the COVID-19 pandemic, a practice that has a high potential to increase maternal and child morbidity and mortality. Methods: Data from three survey rounds of the Iracema-COVID cohort study, collected 6, 12, and 18 months after birth, showed the patterns of postpartum attendance to primary health care consultation of the mother-child dyad. Crude and adjusted multinomial logistic regressions with robust variance were used to assess factors associated with nonattendance. Results: Among the 314 cohort mothers, 25% did not attend any primary health care consultation during the 18-months postpartum, while 30% of the mothers did all three. Regarding the child, 75% had regular primary health care consultations in all three survey rounds, while 4% did not attend any in their first 18 months of life. By the end of the first COVID-19 wave, the proportion of mother and child who attended the consultations had fallen by 23 and 18%, respectively. The main factors associated with nonattendance were mothers aged below 25 years, and mothers with more than one child. Conclusion: An important delay or nonattendance to primary health care consultation by the mother-child dyad was observed during the COVID-19 pandemic. Such practice, with a high potential to increase maternal and child morbidity and mortality, was particularly frequent among younger mothers and those with more than one child.
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Jowell AR, Sarma AA, Gulati M, Michos ED, Vaught AJ, Natarajan P, Powe CE, Honigberg MC. Interventions to Mitigate Risk of Cardiovascular Disease After Adverse Pregnancy Outcomes: A Review. JAMA Cardiol 2021; 7:346-355. [PMID: 34705020 DOI: 10.1001/jamacardio.2021.4391] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance A growing body of evidence suggests that adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy, gestational diabetes (GD), preterm birth, and intrauterine growth restriction, are associated with increased risk of cardiometabolic disease and cardiovascular disease (CVD) later in life. Adverse pregnancy outcomes may therefore represent an opportunity to intervene to prevent or delay onset of CVD. The objective of this review was to summarize the current evidence for targeted postpartum interventions and strategies to reduce CVD risk in women with a history of APOs. Observations A search of PubMed and Ovid for English-language randomized clinical trials, cohort studies, descriptive studies, and guidelines published from January 1, 2000, to April 30, 2021, was performed. Four broad categories of interventions were identified: transitional clinics, lifestyle interventions, pharmacotherapy, and patient and clinician education. Observational studies suggest that postpartum transitional clinics identify women who are at elevated risk for CVD and may aid in the transition to longitudinal primary care. Lifestyle interventions to increase physical activity and improve diet quality may help reduce the incidence of type 2 diabetes in women with prior GD; less is known about women with other prior APOs. Metformin hydrochloride may prevent development of type 2 diabetes in women with prior GD. Evidence is lacking in regard to specific pharmacotherapies after other APOs. Cardiovascular guidelines endorse using a history of APOs to refine CVD risk assessment and guide statin prescription for primary prevention in women with intermediate calculated 10-year CVD risk. Research suggests a low level of awareness of the link between APOs and CVD among both patients and clinicians. Conclusions and Relevance These findings suggest that transitional clinics, lifestyle intervention, targeted pharmacotherapy, and clinician and patient education represent promising strategies for improving postpartum maternal cardiometabolic health in women with APOs; further research is needed to develop and rigorously evaluate these interventions. Future efforts should focus on strategies to increase maternal postpartum follow-up, improve accessibility to interventions across diverse racial and cultural groups, expand awareness of sex-specific CVD risk factors, and define evidence-based precision prevention strategies for this high-risk population.
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Affiliation(s)
- Amanda R Jowell
- Currently a medical student at Harvard Medical School, Boston, Massachusetts
| | - Amy A Sarma
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston.,Corrigan Women's Heart Health Program, Massachusetts General Hospital, Boston
| | - Martha Gulati
- Division of Cardiology, University of Arizona, Phoenix
| | - Erin D Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arthur J Vaught
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Surgical Critical Care, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pradeep Natarajan
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston.,Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts.,Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Camille E Powe
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Diabetes Unit, Endocrine Division, Department of Medicine, Massachusetts General Hospital, Boston
| | - Michael C Honigberg
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston.,Corrigan Women's Heart Health Program, Massachusetts General Hospital, Boston.,Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts.,Cardiovascular Research Center, Massachusetts General Hospital, Boston
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48
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Kern-Goldberger A, Hirshberg A. Reducing Disparities Using Telehealth Approaches for Postdelivery Preeclampsia Care. Clin Obstet Gynecol 2021; 64:375-383. [PMID: 33904843 DOI: 10.1097/grf.0000000000000605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The management of hypertensive disease of pregnancy presents an ongoing challenge after patients are discharged from delivery hospitalizations. Preeclampsia and other forms of postpartum hypertension increase the risk for severe maternal morbidity and mortality in the postpartum period, and both hypertension and its associated adverse events disproportionately affect black women. With its ability to transcend barriers to health care access, telemedicine can facilitate high-quality postpartum care delivery for preeclampsia management and thereby reduce racial disparities in obstetric care and outcomes. Here we discuss racial disparities in preeclampsia and the challenge of providing equitable postpartum preeclampsia care. We then describe the utility of novel telemedicine platforms and their application to combat these disparities in preeclampsia care.
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Affiliation(s)
- Adina Kern-Goldberger
- Department of Obstetrics & Gynecology, Maternal Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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49
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Davis MB, Arendt K, Bello NA, Brown H, Briller J, Epps K, Hollier L, Langen E, Park K, Walsh MN, Williams D, Wood M, Silversides CK, Lindley KJ. Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 1/5. J Am Coll Cardiol 2021; 77:1763-1777. [PMID: 33832604 DOI: 10.1016/j.jacc.2021.02.033] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 01/10/2023]
Abstract
The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.
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Affiliation(s)
- Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | - Katherine Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Haywood Brown
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
| | - Joan Briller
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kelly Epps
- Division of Cardiology, Inova Heart and Vascular Institute, Fairfax, Virginia, USA
| | - Lisa Hollier
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Elizabeth Langen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Mary Norine Walsh
- Division of Cardiology, St. Vincent Heart Center, Indianapolis, Indiana, USA
| | - Dominique Williams
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Malissa Wood
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Candice K Silversides
- Division of Cardiology, Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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50
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Fitzsimmons E, Arany Z, Howell EA, Lewey J. Differential Outcomes for African-American Women with Cardiovascular Complications of Pregnancy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00863-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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