Telehealth with remote blood pressure monitoring compared with standard care for postpartum hypertension

Ensuring safe and equitable discharge: a quality improvement initiative for individuals with hypertensive disorders of pregnancy

OBJECTIVE

To improve timely and equitable access to postpartum blood pressure (BP) monitoring in individuals with hypertensive disorders of pregnancy (HDP).

METHODS

A quality improvement initiative was implemented at a large academic medical centre in the USA for postpartum individuals with HDP. The primary aim was to increase completed BP checks within 7 days of hospital discharge from 40% to 70% in people with HDP in 6 months. Secondary aims included improving rates of scheduled visits, completed visits within 3 days for severe HDP and unattended visits. The balancing measure was readmission rate. Statistical process control charts were used, and data were stratified by race and ethnicity. Direct feedback from birthing individuals was obtained through phone interviews with a focus on black birthing people after a racial disparity was noted in unattended visits.

RESULTS

Statistically significant improvements were noted across all measures. Completed and scheduled visits within 7 days of discharge improved from 40% to 76% and 61% to 90%, respectively. Completed visits within 3 days for individuals with severe HDP improved from 9% to 49%. The unattended visit rate was 26% at baseline with non-Hispanic black individuals 2.3 times more likely to experience an unattended visit than non-Hispanic white counterparts. The unattended visit rate decreased to 15% overall with an elimination of disparity. A need for BP devices at discharge and enhanced education for black individuals was identified through patient feedback.

CONCLUSION

Timely follow-up of postpartum individuals with HDP is challenging and requires modification to our care delivery. A hospital-level quality improvement initiative using birthing individual and frontline feedback is illustrated to improve equitable, person-centred care.

Report from a text-based blood pressure monitoring prospective cohort trial among postpartum women with hypertensive disorders of pregnancy

BACKGROUND

Hypertensive disorders of pregnancy are a main cause of maternal morbidity and mortality in the United States and worldwide, and it is estimated that approximately 60% of maternal deaths in the United States occur during the postpartum period. The utilization of telehealth modalities such as home blood pressure monitoring has shown improvement in blood pressure control and adherence with follow up visits. Our study sought to determine if standardized education improved patient hypertension knowledge and if this when combined with home blood pressure telemonitoring increased participants' postpartum self-blood pressure monitoring and postpartum visit attendance.

METHODS

This is an Institutional Review Board approved prospective cohort study conducted at the University of Mississippi Medical Center. Women with a hypertensive disorder of pregnancy who met the inclusion criteria and provided written informed consent to participate were enrolled. Participants received a baseline pre-education questionnaire designed to assess their knowledge of their hypertensive diagnosis, hypertension management, and postpartum preeclampsia (PreE). Participants then received standard education, a blood pressure monitor, and were scheduled a follow-up visit during the first 10 days following discharge. Remote home blood pressure monitoring was performed via text messages and voice calls for 6-weeks postpartum. At the conclusion of the study, participants repeated their original questionnaire.

RESULTS

250 women provided informed consent to participate in the study and were included in this analysis. Relative to the baseline survey, there was a significant increase (p = 0.0001) in the percentage of correct responses. There was not an association between study engagement and percentage of correct responses on end of study questionnaire (p = 0.33) or postpartum visit attendance (p = 0.69). Maternal age was found to drive study engagement, even when adjusted for community-level distress (p = 0.03) and maternal race (p = 0.0002).

CONCLUSION

Implementing a standardized postpartum education session was associated with improvement in patient's knowledge. Further studies are needed with more longitudinal follow up to assess if this program would also result in improved long-term outcomes and decreased hospital readmission rates.

TRIAL REGISTRATION

NCT04570124.

Improving obstetric and perinatal outcomes with a remote patient monitoring program for hypertension in a large integrated care system

OBJECTIVE

To determine the effect of a remote patient monitoring program for hypertension (RPM HTN) in patients diagnosed with hypertensive disorders of pregnancy.

STUDY DESIGN

We used a matched retrospective cohort design to evaluate differences in obstetric and perinatal outcomes using data from electronic medical records. Patients enrolled in RPM HTN between November 1, 2019, and October 31, 2021, who delivered a pregnancy at ≥20 weeks gestation were compared to a cohort of patients matched by age, race, HTN and diabetes status, who delivered in the 48-month period before implementation of RPM HTN.

RESULTS

1030 patients were enrolled in RPM HTN and 937 were matched to historical controls. Five hundred and seventeen (50.2 %) were enrolled in the antepartum period and 513 (49.8 %) were enrolled postpartum. Patients in the RPM HTN cohort were more likely to have a post-hospital discharge blood pressure (BP) measured within the first 20 days after delivery (RR 1.56, 95 % CI: 1.47-1.65: p < 0.01) and were more likely to have that BP be normal (RR 1.43, 95 % CI: 1.31-1.55: p = 0.05). They were also more likely to be taking antihypertensives postpartum (RR 1.27, 95 % CI: 1.15-1.40; p < 0.01) and to be evaluated by an obstetric clinician within 20 days of delivery (RR 1.50, 95 % CI 1.42-1.58; p < 0.01).

CONCLUSIONS

A remote HTN monitoring program for 937 obstetric patients was associated with improved BP monitoring, better postpartum BP control, and improved linkages to clinician care after delivery, when compared to historical controls.

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

OBJECTIVE

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

DESIGN

Retrospective cohort.

SETTING

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

PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluating Racial Disparities in Implementation and Monitoring of a Remote Blood Pressure Program in a Pregnant Population-A Retrospective Cohort Study

Background: Whether remote blood pressure (BP) monitoring can decrease racial disparities in BP measurement during pregnancy and the postpartum period remains unclear. This study evaluated whether Black and White patients enrolled in the Connected Maternity Online Monitoring (CMOM) program showed improvements in BP ascertainment and interval. Methods: A retrospective cohort of 3,976 pregnant patients enrolled in CMOM were compared to matched usual care patients between January 2016 and September 2022 using electronic health record data. The primary outcomes were BP ascertainment (number of BP measurements) and BP interval (time between BP measurements) during pregnancy and the postpartum period. The proportion of patients with a hypertensive disorder of pregnancy who checked their BP within 7 days of discharge following delivery was also assessed. Results: Enrollment in CMOM was lower among Black patients than White patients (42.1% vs 54.7%, P<0.0001). Patients in the CMOM group had more BP measurements than patients in the usual care group during pregnancy (rate ratio=1.78, 95% CI 1.74-1.82) and the postpartum period (rate ratio=1.30, 95% CI 1.23-1.37), with significant improvements for both Black and White patients enrolled in CMOM compared to patients in usual care. The CMOM intervention did not result in an improvement in 7-day postpartum adherence to checking BP for Black patients (risk ratio=1.03, 95% CI 0.94-1.11) as it did for White patients (risk ratio=1.09, 95% CI 1.01-1.17). Conclusion: Remote BP monitoring programs are a helpful tool to improve the frequency of BP measurements and shorten intervals between measurements during the prenatal and postpartum periods for all patients. Future evaluation is needed to determine the barriers to offering the program to and enrolling Black patients.

Pregnancy-related risk factors and receipt of postpartum care among Texas Medicaid pregnant enrollees: Opportunities for pharmacist services

BACKGROUND

The United States (US) experiences the highest rate of maternal mortality of similar countries. Postpartum care (PPC) focused on chronic disease management is potentially lifesaving, especially among pregnancies complicated by risk factors such as diabetes, hypertension, and mental health conditions (MHCs), which are conditions in which pharmacists can have an impact.

OBJECTIVE

To evaluate the prevalence of maternal mortality risk factors and their relationships with receipt of PPC among Texas Medicaid enrollees.

METHODS

A retrospective study included women with a delivery between 3/25/2014-11/1/2019 who were continuously enrolled in Texas Medicaid during the study period from 84 days pre-delivery to 60 days post-delivery. PPC was defined as ≥1 visit associated with postpartum follow-up services. Maternal mortality risk factors (diabetes, hypertension, and MHCs) during and after pregnancy were identified using diagnoses and medication utilization. Age, race/ethnicity, cesarean delivery, and preterm birth served as covariates. Multivariable logistic regression was used to address the study objective.

RESULTS

The sample (N = 617,010) was 26.5±5.7 years, primarily (52.8%) Hispanic, and 33.0% had cesarean deliveries and 9.3% had preterm births. Risk factor prevalence included: diabetes (14.0%), hypertension (14.3%), and MHCs during (6.3%) and after (9.1%) pregnancy. A majority (77.9%) had a PPC visit within 60 days of delivery. The odds of receiving PPC were 1.2 times higher for patients with diabetes (OR = 1.183; 95% CI = 1.161-1.206; P < 0.0001), 1.1 times higher for patients with hypertension (OR = 1.109; 95% CI= 1.089-1.130; P < 0.0001), and 1.1 times higher for patients with MHCs (OR=1.138; 95% CI = 1.108-1.170; P < 0.0001) than patients without, respectively.

CONCLUSION

Over three-quarters of Texas Medicaid pregnant enrollees received PPC within 60 days of delivery and risk factors were prevalent and predictive of receipt of PPC. Pharmacists can have a positive impact on maternal health by addressing hypertension, diabetes, and MHC risk factors.

Long-Term Blood Pressure Control After Hypertensive Pregnancy Following Physician-Optimized Self-Management: The POP-HT Randomized Clinical Trial

Importance

Pregnancy hypertension results in adverse cardiac remodeling and higher incidence of hypertension and cardiovascular diseases in later life.

Objective

To evaluate whether an intervention designed to achieve better blood pressure control in the postnatal period is associated with lower blood pressure than usual outpatient care during the first 9 months postpartum.

Design, Setting, and Participants

Randomized, open-label, blinded, end point trial set in a single hospital in the UK. Eligible participants were aged 18 years or older, following pregnancy complicated by preeclampsia or gestational hypertension, requiring antihypertensive medication postnatally when discharged. The first enrollment occurred on February 21, 2020, and the last follow-up, November 2, 2021. The follow-up period was approximately 9 months.

Interventions

Participants were randomly assigned 1:1 to self-monitoring along with physician-optimized antihypertensive titration or usual postnatal care.

Main Outcomes and Measures

The primary outcome was 24-hour mean diastolic blood pressure at 9 months postpartum, adjusted for baseline postnatal blood pressure.

Results

Two hundred twenty participants were randomly assigned to either the intervention group (n = 112) or the control group (n = 108). The mean (SD) age of participants was 32.6 (5.0) years, 40% had gestational hypertension, and 60% had preeclampsia. Two hundred participants (91%) were included in the primary analysis. The 24-hour mean (SD) diastolic blood pressure, measured at 249 (16) days postpartum, was 5.8 mm Hg lower in the intervention group (71.2 [5.6] mm Hg) than in the control group (76.6 [5.7] mm Hg). The between-group difference was -5.80 mm Hg (95% CI, -7.40 to -4.20; P < .001). Similarly, the 24-hour mean (SD) systolic blood pressure was 6.5 mm Hg lower in the intervention group (114.0 [7.7] mm Hg) than in the control group (120.3 [9.1] mm Hg). The between-group difference was -6.51 mm Hg (95% CI, -8.80 to -4.22; P < .001).

Conclusions and Relevance

In this single-center trial, self-monitoring and physician-guided titration of antihypertensive medications was associated with lower blood pressure during the first 9 months postpartum than usual postnatal outpatient care in the UK.

Trial Registration

ClinicalTrials.gov Identifier: NCT04273854.

Remote Monitoring Compared With In-Office Surveillance of Blood Pressure in Patients With Pregnancy-Related Hypertension: A Randomized Controlled Trial

OBJECTIVE

To compare the rate of blood pressure ascertainment within 10 days of postpartum discharge among individuals with hypertensive disorders of pregnancy randomized either to in-office blood pressure assessment or at-home monitoring.

METHODS

This was a multisite randomized controlled trial of postpartum patients diagnosed with a hypertensive disorder of pregnancy before discharge between April 2021 and September 2021 and was performed at two academic training institutions. Patients were randomized to either an in-office blood pressure check or remote monitoring through a web-enabled smartphone platform. The primary outcome was the rate of any blood pressure ascertainment within 10 days of discharge. Secondary outcomes include rates of initiation of antihypertensive medication, readmission, and additional office or triage visits for hypertension. Assuming a 10-day postdischarge blood pressure ascertainment rate of 50% in the in-office arm, we estimated that 186 participants would provide 80% power to detect a 20% difference in the primary outcome between groups.

RESULTS

One hundred ninety-seven patients were randomized (96 remote, 101 in-office). Patients with remote monitoring had higher rates of postpartum blood pressure ascertainment compared with in-office surveillance (91.7% [n=88] vs 58.4% [n=59]; P<.001). There were 11 (11.5%) patients in the intervention arm whose only qualifying blood pressure was a postdischarge in-person ascertainment, yielding a true remote monitoring uptake rate of 80.2%. In those with remote blood pressure uptake (n=77), the median number of blood pressure checks was 15 (interquartile range 6-26) and the median duration of remote monitoring use was 14 days (interquartile range 9-16). There were no differences in rates of readmission for hypertension (5.0% [n=5] vs 4.2% [n=4], P=.792) or initiation of antihypertensive medications after discharge (9.4% [n=9] vs 6.9% [n=7], P=.530). Rates of unscheduled visits were increased in the remote monitoring arm, but this did not reach statistical significance (5.0% [n=5] vs 12.5% [n=12], P=.059). When stratifying the primary outcome by race and randomization group, Black patients had lower rates of blood pressure ascertainment than White patients when assigned to in-office surveillance (41.2% [n=14] vs 69.5% [n=41], P=.007), but there was no difference in the remote management group (92.9% [n=26] vs 92.9% [n=52], P>.99).

CONCLUSION

Remote monitoring can increase postpartum blood pressure ascertainment within 10 days of discharge for women with hypertensive disorders of pregnancy and has the potential to promote health equity.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04823949.

Recognizing Early Warning Signs of Acute Hypertensive Crisis of the Postpartum Mother: An Important Role for Neonatal Nurses

A delay in detecting acute hypertensive crisis in postpartum mothers can exacerbate complications in the mother. Neonatal nurses are uniquely qualified to identify postpartum warning signs in mothers while they are in the NICU with their infants. Few research studies have explored the use of neonatal nurse screenings for acute hypertensive crisis in postpartum mothers. NICU nurses screening mothers for postpartum depression has yielded success in improving outcomes, and this model could be translated into screening for acute hypertensive crisis. Further education should be implemented for NICU nurses that include a review of adult blood pressure monitoring, early warning signs, and symptoms of preeclampsia that the mother should report. This article discusses the importance of the neonatal nurse's role in identifying early warning signs of maternal postpartum hypertensive crisis.

An evaluation of the efficacy and the safety of home blood pressure monitoring in the control of hypertensive disorders of pregnancy in both pre and postpartum periods: a systematic review and meta-analysis

BACKGROUND

Hypertensive disorders of pregnancy (HDP) can significantly impact maternal, neonatal, and fetal health. For controlling these disorders, frequent blood pressure measurements are required. Home blood pressure monitoring (HBPM) is a suggested alternative to conventional office monitoring that requires frequent visits. This systematic review was conducted to evaluate the efficacy and safety of HBPM in the control of HDP.

METHODS

We systematically conducted databases search for relevant studies in June 2022. The relevant studies were identified, and qualitative synthesis was performed. An inverse variance quantitative synthesis was conducted using RevMan software. Continuous outcome data were pooled as means differences, whereas dichotomous ones were summarized as risk ratios. The 95% confidence interval was the measure of variance.

RESULTS

Fifteen studies were included in our review (n = 5335). Our analysis revealed a superiority of HBPM in reducing the risk of induction of labor, and postpartum readmission (P = 0.02, and 0.01 respectively). Moreover, the comparison of birth weights showed a significant variation in favor of HBPM (P = 0.02). In the analysis of other outcomes, HBPM was equally effective as office monitoring. Furthermore, HBPM did not result in an elevated risk of maternal, neonatal, and fetal adverse outcomes.

CONCLUSION

Home monitoring of blood pressure showed superiority over office monitoring in some outcomes and equal efficacy in other outcomes.

Postpartum remote home blood pressure monitoring: the new frontier

There has been an alarming and substantial increase in hypertensive disorders of pregnancy, which are a significant driver of maternal morbidity and mortality. The postpartum period is an especially high-risk time, with >50% of pregnancy-related deaths and significant morbidity occurring during this period. The American College of Obstetricians and Gynecologists suggests inpatient or equivalent monitoring of blood pressures in patients with hypertensive disorders of pregnancy for the immediate 72 hours postpartum and again within 7 to 10 days postpartum. Hypertensive disorders of pregnancy significantly contribute to healthcare costs through increasing admission lengths, rates of readmissions, the number of medications given, and laboratory studies ordered, and through the immeasurable impact on the patient and society. Telemedicine is an essential option for patients with barriers to accessing care, particularly those in remote areas with difficulty accessing subspecialty care, transportation, childcare, or job security. The implementation of these programs also has potential to mitigate racial inequities given that patients of color are disproportionately affected by the morbidity and mortality of hypertensive disorders of pregnancy. Remote blood pressure monitoring programs are generally acceptable, with high levels of satisfaction in the obstetrical population without posing an undue burden of care. Studies have reported different, but encouraging, measures of feasibility, including rates of recruitment, consent, engagement, adherence, and retention in their programs. Considering these factors, the widespread adoption of postpartum blood pressure monitoring programs holds promise to improve the identification and care of this at-risk population. These immediate clinical effects are significant and can reduce short-term hypertension-related morbidity and even mortality, with the potential for long-term benefit with culturally competent, well-reimbursed, and widespread use of these programs. This clinical opinion aims to show that remote monitoring of postpartum hypertensive disorders of pregnancy is a reliable and effective alternative to current follow-up care models that achieves improved blood pressure control and diminishes racial disparities in care while simultaneously being acceptable to providers and patients and cost-saving to hospital systems.

Standardized Clinical Assessment and Management Plan to Reduce Readmissions for Postpartum Hypertension

OBJECTIVE

To evaluate the effect of a postpartum hypertension standardized clinical assessment and management plan on postpartum readmissions and emergency department (ED) visits.

METHODS

We conducted a prospective cohort study of patients with postpartum hypertension (either chronic hypertension or hypertensive disorders of pregnancy) who delivered at a single tertiary care center for 6 months after enacting an institution-wide standardized clinical assessment and management plan (postintervention group). Patients in the postintervention group were compared with patients in a historical control group. The standardized clinical assessment and management plan included 1) initiation or uptitration of medication for any blood pressure (BP) higher than 150/100 mm Hg or any two BPs higher than 140/90 mm Hg within a 24-hour period, with the goal of achieving normotension (BP lower than 140/90 mm Hg) in the 12 hours before discharge; and 2) enrollment in a remote BP monitoring system on discharge. The primary outcome was postpartum readmission or ED visit for hypertension. Multivariable logistic regression was used to evaluate the association between standardized clinical assessment and management plan and the selected outcomes. A sensitivity analysis was performed with propensity score weighting. A planned subanalysis in the postintervention cohort identified risk factors associated with requiring antihypertensive uptitration after discharge. For all analyses, the level of statistical significance was set at P<.05.

RESULTS

Overall, 390 patients in the postintervention cohort were compared with 390 patients in a historical control group. Baseline demographics were similar between groups with the exception of lower prevalence of chronic hypertension in the postintervention cohort (23.1% vs 32.1%, P=.005). The primary outcome occurred in 2.8% of patients in the postintervention group and in 11.0% of patients in the historical control group (adjusted odds ratio [aOR] 0.24, 95% CI 0.12-0.49, P<.001). A matched propensity score analysis controlling for chronic hypertension similarly demonstrated a significant reduction in the incidence of the primary outcome. Of the 255 patients (65.4%) who were compliant with outpatient remote BP monitoring, 53 (20.8%) had medication adjustments made per protocol at a median of 6 days (interquartile range 5-8 days) from delivery. Non-Hispanic Black race (aOR 3.42, 95% CI 1.68-6.97), chronic hypertension (aOR 2.09, 95% CI 1.13-3.89), having private insurance (aOR 3.04, 95% CI 1.06-8.72), and discharge on antihypertensive medications (aOR 2.39, 95% CI 1.33-4.30) were associated with requiring outpatient adjustments.

CONCLUSION

A standardized clinical assessment and management plan significantly reduced postpartum readmissions and ED visits for patients with hypertension. Close outpatient follow-up to ensure appropriate medication titration after discharge may be especially important in groups at high risk for readmission.

Postpartum Home Blood Pressure Monitoring: A Systematic Review

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.

Pregnancy as an Early Cardiovascular Moment: Peripartum Cardiovascular Health

Pregnancy is commonly referred to as a window into future CVH (cardiovascular health). During pregnancy, physiological adaptations occur to promote the optimal growth and development of the fetus. However, in approximately 20% of pregnant individuals, these perturbations result in cardiovascular and metabolic complications, which include hypertensive disorders of pregnancy, gestational diabetes, preterm birth, and small-for-gestational age infant. The biological processes that lead to adverse pregnancy outcomes begin before pregnancy with higher risk of adverse pregnancy outcomes observed among those with poor prepregnancy CVH. Individuals who experience adverse pregnancy outcomes are also at higher risk of subsequent development of cardiovascular disease, which is largely explained by the interim development of traditional risk factors, such as hypertension and diabetes. Therefore, the peripartum period, which includes the period before (prepregnancy), during, and after pregnancy (postpartum), represents an early cardiovascular moment or window of opportunity when CVH should be measured, monitored, and modified (if needed). However, it remains unclear whether adverse pregnancy outcomes reflect latent risk for cardiovascular disease that is unmasked in pregnancy or if adverse pregnancy outcomes are themselves an independent and causal risk factor for future cardiovascular disease. Understanding the pathophysiologic mechanisms and pathways linking prepregnancy CVH, adverse pregnancy outcomes, and cardiovascular disease are necessary to develop strategies tailored for each stage in the peripartum period. Emerging evidence suggests the utility of subclinical cardiovascular disease screening with biomarkers (eg, natriuretic peptides) or imaging (eg, computed tomography for coronary artery calcium or echocardiography for adverse cardiac remodeling) to identify risk-enriched postpartum populations and target for more intensive strategies with health behavior interventions or pharmacological treatments. However, evidence-based guidelines focused on adults with a history of adverse pregnancy outcomes are needed to prioritize the prevention of cardiovascular disease during the reproductive years and beyond.

Electronic Reminder to Transition Care After Hypertensive Disorders of Pregnancy: A Randomized Controlled Trial

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.

Remote blood pressure monitoring in high risk pregnancy - study protocol for a randomised controlled trial (REMOTE CONTROL trial)

BACKGROUND

Pregnant women at high risk for developing a hypertensive disorder of pregnancy require frequent antenatal assessments, especially of their blood pressure. This expends significant resources for both the patient and healthcare system. An alternative to in-clinic assessments is a remote blood pressure monitoring strategy, in which patients self-record their blood pressure at home using a validated blood pressure machine. This has the potential to be cost-effective, increase patient satisfaction, and reduce outpatient visits, and has had widespread uptake recently given the increased need for remote care during the ongoing COVID-19 pandemic. However robust evidence supporting this approach over a traditional face-to-face approach is lacking, and the impact on maternal and foetal outcomes has not yet been reported. Thus, there is an urgent need to assess the efficacy of remote monitoring in pregnant women at high risk of developing a hypertensive disorder of pregnancy.

METHODS

The REMOTE CONTROL trial is a pragmatic, unblinded, randomised controlled trial, which aims to compare remote blood pressure monitoring in high-risk pregnant women with conventional face-to-face clinic monitoring, in a 1:1 allocation ratio. The study will recruit patients across 3 metropolitan Australian teaching hospitals and will evaluate the safety, cost-effectiveness, impact on healthcare utilisation and end-user satisfaction of remote blood pressure monitoring.

DISCUSSION

Remote blood pressure monitoring is garnering interest worldwide and has been increasingly implemented following the COVID-19 pandemic. However, robust data regarding its safety for maternofoetal outcomes is lacking. The REMOTE CONTROL trial is amongst the first randomised controlled trials currently underway, powered to evaluate maternal and foetal outcomes. If proven to be as safe as conventional clinic monitoring, major potential benefits include reducing clinic visits, waiting times, travel costs, and improving delivery of care to vulnerable populations in rural and remote communities.

TRIAL REGISTRATION

The trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12620001049965p, on October 11th, 2020).

Blood pressure changes in gestational hypertension, preeclampsia, and chronic hypertension from preconception to 42-day postpartum

OBJECTIVE

To investigate blood pressure changes from preconception to 42-day postpartum in patients with gestational hypertension, preeclampsia, and chronic hypertension.

STUDY DESIGN

Secondary analysis of patients diagnosed with a hypertensive disorder of pregnancy (HDP) antenatally or postpartum, who were enrolled prospectively in a postpartum remote blood pressure (BP) monitoring program between March 2017 and May 2020. BP were collected at 47 time points: preconception, each trimester, delivery day, and every postpartum day through 42-days postpartum. The primary outcome of the study was to examine changes in BP over time and between the types of HDP for 42 days postpartum. Secondary outcomes included the difference in timing of BP stabilization (BPs < 140/90 mmHg for ≥ 48 h), BP resolution (stabilized without antihypertensive medication use), and antihypertensive medication usage at 42-day postpartum between the HDP groups.

RESULTS

A total of 1,194 patients were included in the cohort; 224 (18.8 %) had chronic hypertension (CHTN), 525 (43.9 %) had gestational hypertension (GHTN), 153 (12.8 %) had preeclampsia, and 292 (24.5 %) had preeclampsia with severe features. Postpartum BP peaked on days 5-7 postpartum with rapid decrease from postpartum day 7 until postpartum day 14, followed by very small resolution/stabilization in BP values between day 15 and 42 postpartum. By 6 weeks postpartum, 60.5 % of patients with CHTN still required antihypertensive medications to maintain BP < 140/90 mmHg. In the group of patients with preeclampsia with severe features, 32.6 % still required antihypertensive medications to maintain BP < 140/90 mmHg. Finally, 16.1 % patients with GHTN and 23.8 % of patients with preeclampsia without severe features required antihypertensive use at 6 weeks postpartum. The groups of CHTN and GHTN had significant reduction in SBPs at 42-days postpartum compared to their pre-conception BP (p < 0.001 for both groups). While diastolic BP at 42-days postpartum were not different in CHTN, GHTN and preeclampsia groups, compared to preconception, women with preeclampsia with severe features had higher diastolic BP at the end of 6-weeks postpartum period compared to preconception readings (p = 0.007).

CONCLUSION

Our study adds new information by examining BP trajectories through 42 days postpartum and demonstrates that all types of HDP are at risk of BP spikes and intervention through 42 days postpartum. We found that patients with CHTN had slower stabilization and resolution of their BP compared to patients with GHTN and preeclampsia with and without severe features. In addition, even at 42 days postpartum, a substantial proportion of patients with HDP, including GHTN, required antihypertensive treatment to maintain BP within stage I hypertension.

Society for Maternal-Fetal Medicine Special Statement: Telemedicine in obstetrics-quality and safety considerations

The frequency of telemedicine encounters has increased dramatically in recent years. This review summarizes the literature regarding the safety and quality of telemedicine for pregnancy-related services, including prenatal care, postpartum care, diabetes mellitus management, medication abortion, lactation support, hypertension management, genetic counseling, ultrasound examination, contraception, and mental health services. For many of these, telemedicine has several potential or proven benefits, including expanded patient access, improved patient satisfaction, decreased disparities in care delivery, and health outcomes at least comparable to those of traditional in-person encounters. Considering these benefits, it is suggested that payers should reimburse providers at least as much for telemedicine as for in-person services. Areas for future research are considered.

Is remote blood pressure monitoring and management a better approach for patients with hypertension? A narrative review

Hypertension is a global public health problem which affects the physical and mental health of individuals. The management of hypertension is a long-term process that requires the cooperation of both doctors and patients, and the blood pressure variability is closely related to the clinical prognosis. In recent years, the development of telemedicine has promoted better blood pressure monitoring and management for patients, as well as better medical intervention and health education for patients by medical staff. This article provides a review of remote blood pressure monitoring and management.

Does Daily Self-Weighing Contribute to Postpartum Weight Loss? A Secondary Analysis of Daily Postpartum Weights among Women with Hypertensive Disorders of Pregnancy

OBJECTIVE

This study was aimed to examine the impact of daily self-weighing via remote monitoring on postpartum weight loss.

STUDY DESIGN

This was a secondary analysis of a nonrandomized controlled trial comprised of postpartum women with diagnosed hypertensive-related disorders in pregnancy who received a tablet device linked to Bluetooth-enabled equipment including a scale and blood pressure cuff. In addition to blood pressure monitoring, participants were instructed to perform daily self-weighing. The primary outcome of this study was to determine whether postpartum women who performed daily self-weighing lost more weight than those who did not, with a 42-day endpoint based on a 6-week postpartum visit weight.

RESULTS

Overall, 214 women participated in this program and 214 received usual care. Median weight loss for women participating in the remote blood pressure monitoring system was 23.0 (interquartile range [IQR]: 17-30) pounds versus 23.0 (IQR: 17-29) pounds among controls. Weight loss did not vary by prepregnancy obesity (median: 20 pounds [IQR: 17-28 pounds] for nonobese and 23 [IQR: 17-30] pounds for women with obesity, p = 0.16). Women who weighed themselves more than half of follow-up days lost a median of 24 pounds (IQR: 17-30 pounds) compared with 20.5 pounds (IQR: 14-29 pounds), p = 0.06. Women who weighed themselves more than half of follow-up days lost a mean of 11.4% (standard deviation [SD] = 0.41%) of body weight compared with 9.1% (SD = 0.74%; p = 0.01). The amount of weight loss in the telehealth group was correlated with the number of daily weights performed (Pearson's correlation coefficient 0.164, p = 0.025). Postpartum weight loss for daily self-weighing participants was most notable in the first 2 weeks with ongoing weight loss up to the 42-day (6-week) endpoint of this secondary analysis.

CONCLUSION

Daily self-weighing alone may be insufficient to promote postpartum weight loss. However, there was a slight trend toward more weight loss with more frequent weighing.

KEY POINTS

· Daily self-weighing is insufficient for postpartum weight loss.. · Women who weighed themselves more lost slightly more weight.. · Weight loss was the most notable in the first 2 weeks.. · Its use as one part of a program may be worth studying..

Peripartum and Long-Term Maternal Cardiovascular Health After Preeclampsia

There is widespread acceptance of the increased prevalence of cardiovascular diseases occurring within 1 to 2 decades in women following a preeclamptic pregnancy. More recent evidence suggests that the deranged biochemical and echocardiographic findings in women do not resolve in the majority of preeclamptic women following giving birth. Many women continue to be hypertensive in the immediate postnatal period with some exhibiting occult signs of cardiac dysfunction. There is now promising evidence that with close monitoring and effective control of blood pressure control in the immediate postnatal period, women may have persistently lower blood pressures many years after stopping their medication. This review highlights the evidence that delivering effective medical care in the fourth trimester of pregnancy can improve the long-term cardiovascular health after a preeclamptic birth.

Hypertensive Crisis in Pregnancy

Severe hypertension in pregnancy is a medical emergency, defined as systolic blood pressure (BP) ≥ 160 mm Hg and/or diastolic BP ≥ 110 mm Hg taken 15 minutes to 4 or more hours apart. Outside pregnancy, acute severe hypertension (HTN) is defined as a BP greater than 180/110 to 120 reproducible on 2 occasions. The lower threshold for severe HTN in pregnancy reflects the increased risk for adverse outcomes, particularly maternal stroke and death, and may be a source of under-recognition and treatment delay, particularly in nonobstetrical health care settings. Once a severe hypertension episode is recognized, antihypertensive therapy should be initiated as soon as feasibly possible, at least within 30 to 60 minutes. Intravenous (IV) labetalol, hydralazine, and oral immediate-release nifedipine are all recommended first-line agents and should be administered according to available institutional protocols and based on provider knowledge and familiarity.

Best Practices for Managing Postpartum Hypertension

Purpose of Review

Patients remain at risk for persistent and de novo postpartum hypertension related to pregnancy. This review aims to summarize the current definitions, clinical practices, and novel systems innovations and therapies for postpartum hypertension.

Recent Findings

Recent changes to the definitions of hypertension outside of pregnancy have not yet impacted definitions or management of hypertensive disorders of pregnancy (HDP), though research examining the implications of these new definitions on risks of developing HDP and the resultant sequelae is ongoing. The administration of diuretics has been shown to reduce postpartum hypertension among women with HDP. Widespread implementation of telemedicine models and remote assessment of ambulatory blood pressures has increased data available on postpartum blood pressure trajectories, which may impact clinical management. Additionally, policy changes such as postpartum Medicaid extension and an increasing emphasis on building bridges to primary care in the postpartum period may improve long-term outcomes for women with postpartum hypertension. Prediction models utilizing machine learning are an area of ongoing research to assist with risk assessment in the postpartum period.

Summary

The clinical management of postpartum hypertension remains focused on blood pressure control and primary care transition for cardiovascular disease risk reduction. In recent years, systemic innovations have improved access through implementation of new care delivery models. However, the implications of changing definitions of hypertension outside of pregnancy, increased data assessing blood pressure trajectories in the postpartum period, and the creation of new risk prediction models utilizing machine learning remain areas of ongoing research.

Society for Maternal-Fetal Medicine Special Statement: Quality metric for timely postpartum follow-up after severe hypertension

Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality. Because postpartum exacerbation of severe hypertension is common, the American College of Obstetricians and Gynecologists recommends that patients with severe hypertension during the childbirth hospitalization be seen within 72 hours after discharge. In this statement, the Society for Maternal-Fetal Medicine proposes a uniform metric reflecting the rate of timely postpartum follow-up of patients with severe hypertension. The metric is designed to be measured using automated calculations based on billing codes derived from claims data. The metric can be used in quality improvement projects to increase the rate of timely follow-up in patients with severe hypertension during the childbirth hospitalization. Suggested steps for implementing such a project are outlined.

Cardio-Obstetrics: the Next Frontier in Cardiovascular Disease Prevention

Purpose of Review

Internationally, cardiovascular disease (CVD) is the leading cause of death in women. With risk factors for CVD continuing to rise, early identification and management of chronic diseases such as hypertension, diabetes, and obstructive sleep apnea is necessary for prevention. Pregnancy is a natural stress test for women with risk factors who may be predisposed to CVD and offers a unique opportunity to not only recognize disease but also implement effective and long-lasting strategies for prevention.

Recent Findings

Prevention begins before pregnancy, as preconception screening, counseling, and optimization of chronic diseases can improve maternal and fetal outcomes. Throughout pregnancy, women should maintain close follow-up, continued reevaluation of risk factors, with counseling when necessary. Continued healthcare engagement during the “fourth trimester,” 3 months following delivery, allows clinicians to continue monitoring the evolution of chronic diseases, encourage ongoing lifestyle counseling, and connect women with primary care and appropriate specialists if needed. Unfortunately, this postpartum period represents a major care gap, as a significant proportion of most women do not attend their scheduled visits. Social determinants of health including decreased access to care and economic instability lead to increased risk factors throughout pregnancy but particularly play a role in poor compliance with postpartum follow-up. The use of telemedicine clinics and remote monitoring may prove to be effective interventions, bridging the gap between physicians and patients and improving follow-up for at-risk women.

Summary

While many clinicians are beginning to understand the impact of CVD on women, screening and prevention strategies are not often implemented until much later in life. Pregnancy creates an opportunity to begin engaging women in cardiovascular protective strategies before the development of the disease.

Risk of unplanned healthcare utilization in postpartum period for patients with hypertensive disorders of pregnancy

OBJECTIVE

To determine which factors are associated with unplanned postpartum healthcare utilization, including hospital readmission and unplanned outpatient and emergency room visits, in patients with hypertensive disorders of pregnancy (HDP).

STUDY DESIGN

This was a case control study of patients with HDP delivering at a single academic institution from 2014 through 2018. The diagnosis of HDP included chronic hypertension, gestational hypertension, preeclampsia and superimposed preeclampsia. Using bivariate and multivariate analysis, demographic and clinical characteristics were compared between patients who had unplanned healthcare utilization, defined as readmission to the hospital, emergency room visit or unplanned outpatient encounter in the first 6-weeks postpartum, and those patients who did not.

RESULTS

Of the 1427 patients with HDP included in this analysis, 174 (12.2%) had unplanned postpartum healthcare utilization. Maternal non-Hispanic Black race and ethnicity and presence of mild blood pressures on the day of discharge after delivery were associated with higher odds of unplanned healthcare utilization (aOR 1.67, 95% CI 1.08 - 2.56 and aOR 1.59, 95% CI 1.12 - 2.27, respectively). In contrast, presence of chronic hypertension was associated with lower odds of unplanned postpartum healthcare utilization (aOR 0.47, 95% CI 0.28 - 0.79) CONCLUSION: Among postpartum patients with HDP, non-Hispanic Black race and ethnicity and discharge home with mild range blood pressures were associated with higher odds of unplanned healthcare utilization in the first 6 weeks postpartum, while chronic hypertension was associated with lower odds.

Longitudinal blood pressure patterns of women with hypertensive disorders of pregnancy: preconception through postpartum

OBJECTIVE

To investigate the longitudinal blood pressure (BP) pattern of women with hypertensive disorders of pregnancy (HDP) preconception through the postpartum day (PPD) 42.

STUDY DESIGN

A retrospective study of women (≥15 years old) diagnosed with an HDP antenatally or postpartum, who were enrolled prospectively in a postpartum remote BP monitoring program between 3/2017 and 5/2020. BPs were collected from 47-time points: preconception, each trimester, delivery day, and 42 days postpartum. Analysis was conducted utilizing a mixed-effects longitudinal model.

MAIN OUTCOME MEASURES

Primary outcome was the longitudinal BP patterns. Secondary outcomes were the timing of BP stabilization (BPs < 140/90 mmHg for ≥48 h) and resolution (stabilized without antihypertensive medication use).

RESULTS

Our final analysis included 897 of the 964 eligible women. The peak systolic and diastolic BPs were on PPDs 3, 4, 5, and 5, 6, 7, respectively. Systolic BP fell below the preconception level after PPD15; diastolic BP reached its plateau after PPD17 and remained above the preconception level till PPD42 (p < .001). Postpartum BP peaked with the highest percentage of BP spikes on PPDs 4-7. The median survival times to BP stabilization and resolution were PPDs 11 (95% CI: 10-12) and 23 (95% CI: 21-25), respectively. By PPD42, 91.0% and 74.1% of women achieved BP stabilization and resolution, respectively.

CONCLUSION

This study data could be used to develop evidence-based recommendations for women with an HDP. Diastolic BPs remaining significantly higher than the preconception level indicates the long-term risk of cardiovascular disease. In our cohort, 26% of women had unresolved hypertension by PPD42, which reinforces the necessity to ensure long-term follow-up.

Cost-effectiveness of telehealth with remote patient monitoring for postpartum hypertension

OBJECTIVE

Evaluate cost-effectiveness of telehealth with remote monitoring for postpartum hypertensive disorders from the hospital's perspective.

METHODS

A decision tree was developed using results from a non-randomized controlled trial comparing telehealth to standard outpatient blood pressure monitoring. At discharge, postpartum women with a hypertensive disorder received a Bluetooth tablet, blood pressure monitor, and scale to submit vitals daily for 6 weeks. Women were managed and treated with a standard protocol. We performed a cost-effectiveness analysis using data from the hospital, device manufacturer supplied charges, and utilities. A cost-effectiveness threshold was set at $100,000/quality-adjusted life years. One-way and two-way sensitivity analyses were performed to evaluate the robustness of our results compared to baseline assumptions.

RESULTS

Telehealth monitoring significantly reduced postpartum readmissions, 3.7% (8/214) versus 0.5% (1/214), and resulted in higher quality-adjusted life years. Telehealth monitoring was cost-effective and cost-saving. Average cost of telehealth per patient was $309, and was cost-effective to a cost of $420 per patient. Telehealth monitoring remained cost-effective down to an admission cost of $10,999 compared to our baseline-estimate for the average admission cost of $14,401. Telehealth monitoring also remained cost-effective when the postpartum readmission rate was 3.0% or higher with standard monitoring. With a cost saving of $93 per patient and an estimated 333,253 pregnant women with hypertension in the US a year, telehealth could reduce health care costs in the US by approximately $31 million a year.

CONCLUSIONS

This study demonstrates telehealth with remote blood pressure monitoring may be a cost-effective and cost-saving solution for management of postpartum hypertension.