Delayed Postpartum Preeclampsia and Eclampsia: Demographics, Clinical Course, and Complications

Comparison of patients presenting with hypertensive disorders of pregnancy antenatally versus de-novo postpartum hypertension

INTRODUCTION

To describe the characteristics of patient's presenting with postpartum hypertension, comparing those with known hypertensive disorders of pregnancy (HDP) antenatally to patients presenting with de novo postpartum hypertension.

METHODS

A retrospective audit of deliveries at Northern Health from January 2016 to December 2020. International Classification of Diseases (ICD) codes combined with a manual medical records search identified 72 records that resulted in representation to hospital with hypertension. Data was collected to observe and compare maternal, pregnancy and fetal characteristics.

RESULTS

Of the 72 patients, 35 (48.6 %) readmissions had known HDP and 37 (51.4 %) had de novo postpartum HDP. Similarities were observed between both the patients with known HDP and de novo postpartum hypertension group, including maternal age at delivery (32.4 ± 4.9, 31.9 ± 5.6 years), BMI (32 (25-38), 31 (24-41) kg/m2) and nulliparity (48.6 %, 40.5 %). Aspirin prescription was similar in both groups (28.6 %, 27.0 %). The mean birthweight of the known HDP group was significantly less (2893.7 ± 231.4 g) compared to the de novo group (3362.4 ± 584.4 g). Differences were observed in the urine protein to creatinine ratio (uPCr) antenatally. Antenatally and postpartum the blood pressure readings for the known HDP were significantly higher than the de novo group.

CONCLUSIONS

More than 50 % of patients representing are de novo HDP. It does not appear pre-eclampsia is unrecognised antenatally in the de novo group. Our study does not highlight key factors that aid the recognition of those at risk of developing postpartum hypertension separate to the risk factors that are associated with HDP generally.

Determinants of new-onset postpartum preeclampsia among mothers who delivered in hospitals in the South Gondar Zone, Northwest Ethiopia: a multicenter case-control study

BACKGROUND

New-onset postpartum preeclampsia has emerging as a significant public health concern in Ethiopia, with a notable increase in incidence in the study area. While substantial research exists on antepartum preeclampsia, data on the determinants of new-onset postpartum preeclampsia are limited. Therefore, this study aimed to investigate determinants of new-onset postpartum preeclampsia among mothers who gave birth at hospitals in the South Gondar Zone, Northwest Ethiopia.

METHODS

An unmatched case-control study was conducted with 355 postpartum mothers (89 cases and 266 controls). A multistage sampling method was used to select the study participants. Data were collected using structured questionnaires and medical chart reviews, and analyzed using SPSS Version 27. Binary logistic regression (bivariable and multivariable analysis) was used to identify factors associated with new-onset postpartum preeclampsia. Statistical significance was set at p < 0.05, and strength of associations were measured using adjusted odds ratios (AOR) with 95% confidence intervals (CIs).

RESULT

New-onset postpartum preeclampsia was significantly associated with several factors, including advanced maternal age, fewer antenatal care (ANC) visits, contraceptive use, physical inactivity, a history of multiple gestations, and gestational diabetes mellitus. Specifically, maternal age ≥ 40 years (AOR = 11.63, 95% CI: 4.24-31.86), fewer than four ANC visits (AOR = 8.45, 95% CI: 3.96-18.05), contraceptive use (AOR = 4.04, 95% CI: 1.26-13.37), irregular physical activity (AOR = 4.05, 95% CI: 1.32-12.44), physical inactivity (AOR = 8.25, 95% CI: 4.62-19.29), a history of multiple gestations (AOR = 2.66, 95% CI: 1.26-5.60), and gestational diabetes mellitus (AOR = 17.79, 95% CI: 7.72-40.95) were identified as key determinants.

CONCLUSIONS

Advanced maternal age, fewer ANC visits, contraceptive use, physical inactivity, multiple gestations, and gestational diabetes were strongly associated with new-onset postpartum preeclampsia. Increased ANC visits and postpartum monitoring are essential for early detection and management of postpartum preeclampsia. Additionally, promoting physical activity should be incorporated into maternal health strategies to reduce the incidence of new onset postpartum preeclampsia.

Lasix for the prevention of de novo postpartum hypertension: a randomized placebo-controlled trial (LAPP Trial)

BACKGROUND

Birthing people with de novo postpartum hypertensive disorders continue to be among the populations at highest risk for severe maternal morbidity. Randomized controlled trials demonstrate a benefit of oral loop diuretics in decreasing postpartum hypertensive morbidity in patients with an antenatal diagnosis of preeclampsia. It is not known whether this same therapy benefits patients at risk for new-onset postpartum hypertension.

OBJECTIVE

This study aimed to evaluate whether oral furosemide can reduce the risk for de novo postpartum hypertension among high-risk birthing people by reducing postdelivery blood pressure.

STUDY DESIGN

From October 2021 to April 2022, we conducted a randomized triple-masked placebo-controlled clinical trial of individuals at high risk for de novo postpartum hypertension at a single university-based tertiary care medical center. A total of 82 postpartum patients with no antenatal diagnosis of chronic hypertension or a hypertensive disorder of pregnancy who were at high risk for the development of de novo postpartum hypertension based on a prespecified risk factor algorithm were enrolled after childbirth. The participants were randomly assigned in a 1:1 ratio to a 5-day course of 20-mg oral furosemide daily or identical-appearing placebo starting within 8 hours of delivery. Participants were followed for 6 weeks postpartum using Bluetooth-enabled remote blood pressure monitoring and electronic surveys. The primary outcome was mean arterial pressure averaged over the 24 hours before discharge or the 24 hours before antihypertensive therapy initiation. The study was powered to detect a 5 mm Hg difference in average mean arterial pressure (standard deviation, 6.4 mm Hg) with 90% power at an alpha of 0.05, requiring a sample size of 41 per group. Secondary outcomes included the rate of de novo postpartum hypertension, readmission data, other measures of hypertensive and maternal morbidity, breastfeeding data, and drug-related neonatal outcomes.

RESULTS

The primary outcome was assessed in 80 of the 82 participants. Baseline characteristics were similar between the groups. There was no significant difference in average mean arterial pressure in the 24 hours before discharge (or antihypertensive initiation) in the furosemide group (88.9±7.4 mm Hg) compared with the placebo group (86.8±7.1 mm Hg; absolute difference, 2.1 mm Hg; 95% confidence interval, -1.2 to 5.3). Of the 79 participants for whom secondary outcomes were assessed, 10% (n=8) developed de novo postpartum hypertension and 9% (n=7) were initiated on antihypertensive therapy. Rates were not significantly different between the groups (P=.71 and P>.99, respectively).

CONCLUSION

De novo postpartum hypertension is a common phenomenon among at-risk patients, warranting close monitoring for severe hypertension and other maternal morbidity. There is insufficient evidence to suggest that furosemide reduces average mean arterial pressure in the 24 hours before discharge from the delivery hospitalization (or antihypertensive medication initiation) compared with placebo.

Approach to Altered Mental Status in Pregnancy and Postpartum

The evaluation and diagnosis of altered mental status in the pregnant or postpartum patient largely parallels the approach used for any other patient; however, there are several critical differences including that some neuroobstetric diagnoses require emergent delivery of the fetus. Being familiar with the physiological changes and medical complications of pregnancy and delivery is therefore essential. This review first addresses pregnancy-specific disorders that may result in altered mental status, such as the hypertensive disorders of pregnancy and pregnancy-related metabolic and endocrinopathies. The focus then shifts to the complex physiologic changes in pregnancy and how these changes contribute to the distinct epidemiology of pregnancy-related cerebrovascular complications like intracranial hemorrhage, ischemic stroke, and reversible cerebral vasoconstriction syndrome. Medical disorders that are not unique to pregnancy, such as infections and autoimmune conditions, may present de novo or worsen during pregnancy and the peripartum period and require a thoughtful approach to diagnosis and management. Finally, the unique nervous system complications of obstetric anesthesia are explored. In each section, there is a focus not only on diagnosis and syndrome recognition but also on the emergent treatment needed to reverse these complications, bearing in mind the unique physiology of the pregnant patient.

A Mother's struggle: postpartum preeclampsia complicated by triple vessel spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome among young women, especially in the postpartum period. Pregnancy-Associated SCAD (P-SCAD), an aggressive subtype, frequently involves multi-vessel dissection, decreased left ventricular function, and higher mortality. Here we present a rare case of postpartum pre-eclampsia complicated by multi-vessel SCAD in a 40-year-old multiparous Haitian black woman. Diagnosis was established with coronary angiography which revealed spontaneous dissection of the left anterior descendant, left circumflex, and right coronary arteries. Given the patient remained hemodynamically stable no percutaneous coronary intervention was indicated. She experienced recurrent anginal symptoms during her hospitalization that were managed with the addition of clopidogrel. The pathophysiology of P-SCAD is not well understood and thought to be related to an increased state of hemodynamic stress and hormonal fluctuation. The role of pre-eclampsia as a risk factor remains poorly defined and warrants further investigation.

Well-Child Visits for Early Detection and Management of Maternal Postpartum Hypertensive Disorders

Importance

Innovative approaches are needed to address the increasing rate of postpartum morbidity and mortality associated with hypertensive disorders.

Objective

To determine whether assessing maternal blood pressure (BP) and associated symptoms at time of well-child visits is associated with increased detection of postpartum preeclampsia and need for hospitalization for medical management.

Design, Setting, and Participants

This is a pre-post quality improvement (QI) study. Individuals who attended the well-child visits between preimplementation (December 2017 to December 2018) were compared with individuals who enrolled after the implementation of the QI program (March 2019 to December 2019). Individuals were enrolled at an academic pediatric clinic. Eligible participants included birth mothers who delivered at the hospital and brought their newborn for well-child check at 2 days, 2 weeks, and 2 months. A total of 620 individuals were screened in the preintervention cohort and 680 individuals were screened in the QI program. Data was analyzed from March to July 2022.

Exposures

BP evaluation and preeclampsia symptoms screening were performed at the time of the well-child visit. A management algorithm-with criteria for routine or early postpartum visits, or prompt referral to the obstetric emergency department-was followed.

Main Outcome and Measures

Readmission due to postpartum preeclampsia. Comparisons across groups were performed using a Fisher exact test for categorical variables, and t tests or Mann-Whitney tests for continuous variables.

Results

A total of 595 individuals (mean [SD] age, 27.2 [6.1] years) were eligible for analysis in the preintervention cohort and 565 individuals (mean [SD] age, 27.0 [5.8] years) were eligible in the postintervention cohort. Baseline demographic information including age, race and ethnicity, body mass index, nulliparity, and factors associated with increased risk for preeclampsia were not significantly different in the preintervention cohort and postintervention QI program. The rate of readmission for postpartum preeclampsia differed significantly in the preintervention cohort (13 individuals [2.1%]) and the postintervention cohort (29 individuals [5.6%]) (P = .007). In the postintervention QI cohort, there was a significantly earlier time frame of readmission (median [IQR] 10.0 [10.0-11.0] days post partum for preintervention vs 7.0 [6.0-10.5] days post partum for postintervention; P = .001). In both time periods, a total of 42 patients were readmitted due to postpartum preeclampsia, of which 21 (50%) had de novo postpartum preeclampsia.

Conclusions and Relevance

This QI program allowed for increased and earlier readmission due to postpartum preeclampsia. Further studies confirming generalizability and mitigating associated adverse outcomes are needed.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

Posterior Reversible Encephalopathy Syndrome in a Late Postpartum Patient With a Rare Complication of Subarachnoid Hemorrhage

Posterior reversible encephalopathy syndrome (PRES) is considered a neuroclinical syndrome of headache, confusion, visual changes, and seizures associated with neuroimaging findings of posterior cerebral white matter edema. Although the incidence of the syndrome is largely unknown, this condition is becoming increasingly recognized. The prognosis is generally good with most symptoms resolving within one week and lesions on imaging resolving in two weeks. Death and significant neurological disability have been reported but are relatively rare. In this report, we present a 10-day postpartum patient with an atypical history of headache and seizure-like activity. Neuroimaging revealed findings consistent with PRES as well as a rare complication of subarachnoid hemorrhage. This case highlights the importance of clinicians considering preeclampsia/eclampsia-induced PRES when encountering a postpartum patient with headache and hypertension to further reduce morbidity and mortality in this patient population.

Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum

Magnesium sulfate reduces the risk for eclamptic seizures antepartum, intrapartum, and in the immediate postpartum period, however, there are no studies that have evaluated the benefits and risks of magnesium sulfate among women with late postpartum severe hypertension only. Juxtaposed on this clinical uncertainty is the increased incidence of severe hypertension owing to a rise in pregnancies complicated by advanced maternal age, obesity, chronic hypertension, diabetes, and recent protocols for intensive monitoring of blood pressure in the postpartum period. These factors have led to a significant increase in postpartum presentations for the evaluation and management of severe hypertension, in some cases leading to postpartum readmissions for administration of antihypertensive therapy and magnesium sulfate without data demonstrating clear clinical benefit. Postpartum readmissions can have several negative consequences, including interfering with early bonding with a newborn, breastfeeding, and use of scarce healthcare resources. In addition, magnesium sulfate is associated with risks for serious cardiorespiratory depression and bothersome side effects and can delay determining the optimal antihypertensive regimen, which is typically the most pressing clinical need during postpartum presentations of late-postpartum severe hypertension. Eclampsia that occurs more than 48 hours after delivery is rare (constitutes 16% of all cases of eclampsia) and is most commonly preceded by headaches or other cerebral symptoms. In this commentary, we propose an approach to evaluating and managing patients with late postpartum severe hypertension aimed at identifying those women at highest risk for end-organ injury. We recommend that the short- and long-term focus for all patients with severe hypertension should be the optimal management of blood pressures with a goal of close outpatient monitoring when logistically feasible and clinically appropriate. We suggest reserving magnesium sulfate therapy for the subset of patients with neurologic symptoms who may be at highest risk for an eclamptic seizure.

New-onset postpartum hypertension in women without a history of hypertensive disorders of pregnancy: a multicenter study in Japan

The aim of this study was to investigate the prevalence and risk factors of new-onset postpartum hypertension (PPHTN), defined as new-onset hypertension during the postpartum period, among women without a history of hypertension during pregnancy and labor. A multicenter retrospective study was conducted using clinical data of women who delivered at term between 2011 and 2018 at 12 maternity hospitals. A total of 18,295 normotensive women were eligible, after excluding those with hypertensive disorders of pregnancy or hypertension during labor. New-onset PPHTN was defined as multiple blood pressure readings of ≥ 140/90 mmHg between 1 d and 4 weeks postpartum among normotensive women throughout pregnancy. Multivariate regression analyses were performed to evaluate the risk factors for new-onset PPHTN. Among the 18,295 normotensive women, 227 (1.2%) presented with new-onset PPHTN. The prevalence was higher in women who delivered via cesarean section than in those who delivered vaginally (7.0% and 1.0%, respectively). The independent risk factors were maternal age ≥ 35 years (adjusted odds ratio 1.67, 95% confidence interval [1.10-2.53]), nulliparity (1.83 [1.24-2.71]), high normal blood pressure (systolic blood pressure [SBP] 120-129 and diastolic blood pressure [DBP] < 80) at the last prenatal check-up (1.96 [1.23-3.13]), elevated blood pressure (SBP 130-139 and/or DBP 80-89) (6.42 [4.15-9.95]), urinary protein 1+ (1.99 [1.27-3.11]), scheduled cesarean section (4.05 [1.69-9.69]), and emergency cesarean section (10.02 [5.10-19.70]). New-onset PPHTN was observed in 1.2% of the normotensive women, with women who delivered via cesarean section having the highest risk. Close postpartum blood pressure monitoring may be required for women with multiple risk factors to identify new-onset PPHTN in a timely manner and reduce adverse maternal consequences.

Postpartum readmission for hypertension and pre-eclampsia: development and validation of a predictive model

OBJECTIVE

To develop a model for predicting postpartum readmission for hypertension and pre-eclampsia at delivery discharge and assess external validation or model transportability across clinical sites.

DESIGN

Prediction model using data available in the electronic health record from two clinical sites.

SETTING

Two tertiary care health systems from the Southern (2014-2015) and Northeastern USA (2017-2019).

POPULATION

A total of 28 201 postpartum individuals: 10 100 in the South and 18 101 in the Northeast.

METHODS

An internal-external cross validation (IECV) approach was used to assess external validation or model transportability across the two sites. In IECV, data from each health system were first used to develop and internally validate a prediction model; each model was then externally validated using the other health system. Models were fit using penalised logistic regression, and accuracy was estimated using discrimination (concordance index), calibration curves and decision curves. Internal validation was performed using bootstrapping with bias-corrected performance measures. Decision curve analysis was used to display potential cut points where the model provided net benefit for clinical decision-making.

MAIN OUTCOME MEASURES

The outcome was postpartum readmission for either hypertension or pre-eclampsia <6 weeks after delivery.

RESULTS

The postpartum readmission rate for hypertension and pre-eclampsia overall was 0.9% (0.3% and 1.2% by site, respectively). The final model included six variables: age, parity, maximum postpartum diastolic blood pressure, birthweight, pre-eclampsia before discharge and delivery mode (and interaction between pre-eclampsia × delivery mode). Discrimination was adequate at both health systems on internal validation (c-statistic South: 0.88; 95% confidence interval [CI] 0.87-0.89; Northeast: 0.74; 95% CI 0.74-0.74). In IECV, discrimination was inconsistent across sites, with improved discrimination for the Northeastern model on the Southern cohort (c-statistic 0.61 and 0.86, respectively), but calibration was not adequate. Next, model updating was performed using the combined dataset to develop a new model. This final model had adequate discrimination (c-statistic: 0.80, 95% CI 0.80-0.80), moderate calibration (intercept -0.153, slope 0.960, Emax 0.042) and provided superior net benefit at clinical decision-making thresholds between 1% and 7% for interventions preventing readmission. An online calculator is provided here.

CONCLUSIONS

Postpartum readmission for hypertension and pre-eclampsia may be accurately predicted but further model validation is needed. Model updating using data from multiple sites will be needed before use across clinical settings.

Characteristics of Patients Who Attend the 7- to 10-Day Postpartum Visit for Blood Pressure Evaluation

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..

Evaluation and Management of Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy complicate up to 10% of pregnancies and remain the major cause of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy can be classified into four groups depending on the onset of hypertension and the presence of target organ involvement: chronic hypertension, preeclampsia, gestational hypertension, and superimposed preeclampsia on chronic hypertension. Hypertension during pregnancy is associated with a higher risk of cardiovascular disease and kidney failure. Early diagnosis and proper treatment for pregnant women with hypertension remain a priority since this leads to improved maternal and fetal outcomes. Labetalol, nifedipine, methyldopa, and hydralazine are the preferred medications to treat hypertension during pregnancy. In this comprehensive review, we discuss the diagnostic criteria, evaluation, and management of pregnant women with hypertension.

Cardiac Hemangioma: A Rare Tumor Presenting as Postpartum Chest Pain

Pulmonary embolism, peripartum cardiomyopathy, acute myocardial infarction, aortic dissection, anxiety, and gastroesophageal reflux disease are known causes of chest pain during the peripartum period. A cardiac tumor is a rare cause of chest pain during this time period. While cardiac myxomas during pregnancy have been reported, cardiac hemangiomas are exceptionally rare. To the best of our knowledge, there are no existing case reports regarding cardiac hemangiomas in either pregnant or postpartum patients. Here, we present a 23-year-old female who presented with visual changes, headache, and midsternal pain and was subsequently found to have a cardiac hemangioma.

Effect of continuous spinal anesthesia on the hemodynamics of labor analgesia in hypertensive pregnant women: a comparative, randomized clinical trial

BACKGROUND

To observe the changes in hemodynamic, stress and inflammatory responses during labor and their labor outcomes after continuous spinal anesthesia labor analgesia for hypertensive pregnant women, and to evaluate whether the continuous spinal anesthesia had any advantages compared to continuous epidural analgesia for hypertensive pregnant women and their newborns.

METHODS

A total of 160 hypertensive pregnant women were selected and randomly divided into continuous spinal anesthesia analgesia group (CSA group) and continuous epidural analgesia group (EA group). Participant age, height, weight and gestational week were recorded; MAP, VAS score, CO and SVR were recorded after the onset of regular uterine contractions (T₀), 10 min after analgesia (T₁), 30 min (T₂), 60 min (T₃), when the uterine opening was complete (T₄) and when the fetus was delivered (T₅); the duration of the first stage of labor and the second stage of labor were recorded; the number of cases of treatment with oxytocin and antihypertensive therapy, mode of delivery, eclampsia and postpartum hemorrhage were counted; pregnant women Bromage scores were recorded at T₂. We also recorded neonatal weight, Apgar scores at 1, 5 and 10 min after birth; arterial blood gas analysis of the umbilical cord was performed in newborns; finally, TNF-α, IL-6, and cortisol in pregnant women venous blood were measured at T₀, T₅, and 24 h after delivery (T₇). The number of successful compressions and the total drug dosage administered by the analgesic pump were recorded for both groups.

RESULTS

The first stage of labor in CSA was longer than EA (P < 0.05); the MAP, VAS and SVR value in CSA were lower than EA group at T₁, T₃ and T₄ (P < 0.05); in contrast, the CO in CSA at T3 and T4 was higher than in EA (P < 0.05). The oxytocin was more often used whereas the antihypertensive drugs were less used in CSA as compared to EA. The level of TNF-α, IL-6, Cor in the CSA at T5 was lower than the EA group (P < 0.05), and the level of TNF-α in the CSA group at T7 was lower than the EA group (P < 0.05).

CONCLUSION

For pregnant women with hypertension during pregnancy, continuous spinal anesthesia labor analgesia has no significant effect on the final mode of delivery, but shows precise analgesic effect and stabilizes circulatory system, it is recommended to perform continuous spinal anesthesia early in labor for hypertensive pregnant women, which can effectively reduce the stress reaction.

TRIAL REGISTRATION

ChiCTR-INR-17012659. Date of registration: 13/09/2017.

Preeclampsia pathophysiology and adverse outcomes during pregnancy and postpartum

Background

Preeclampsia is a disease with far-reaching consequences that extend beyond the immediate postpartum period and have a significant impact later in life. Preeclampsia exerts an effect on most organ systems in the body. These sequelae are mediated in part by the incompletely elucidated pathophysiology of preeclampsia and the associated vascular changes.

Content

Current research focuses on unraveling the pathophysiology of preeclampsia with the goal of implementing accurate screening and treatment modalities based on disease development and progression. Preeclampsia causes significant short- and long-term maternal morbidity and mortality, not only in the cardiovascular system but also in other organ systems throughout the body. This impact persists beyond pregnancy and the immediate postpartum period.

Summary

The goal of this review is to discuss the current understanding of the pathophysiology of preeclampsia as it relates to the adverse health consequences in patients impacted by this disease, along with a brief discussion of ways to improve overall outcomes.

Changes in maternal heart rate in delayed post-partum preeclampsia

AIM

Delayed-onset postpartum preeclampsia (PET) is defined as a new diagnosis of preeclampsia presenting 48 h to 6 weeks postpartum. This disorder is infrequent and associated with a higher incidence of complications as compared to antepartum PET. There seems to be a need to further characterize this disorder. The aim of the study was to investigate the difference of maternal heart rate in women with delayed onset postpartum preeclampsia as compared to healthy controls.

METHODS

The medical files of all women who were readmitted with delayed onset postpartum preeclampsia during 2014-2020 were reviewed. Data on maternal physiological characteristics were compared to healthy control group of women at the same post-partum day, with uncomplicated pregnancies.

RESULTS

Included 45 women with the diagnosis of delayed onset of preeclampsia at 6.3 ± 2.86 post-partum day. As compared to controls (n = 49), women with delayed post-partum were older, 34.6 ± 5.4 vs. 32.3 ± 4.7 years, p = 0.003. There were no differences between groups regarding maternal gravidity, parity, BMI (kg/m²) or Hb level at delivery day. Women with delayed post-partum preeclampsia had lower mean pulse rate as compared to controls, 58 ± 15 bpm vs. 83 ± 11.6 bpm, respectively, P < 0.0001. Only 17% of the women in the delayed onset group had pulse rate above 70 bpm as compared to 83% in the control group.

CONCLUSIONS

Maternal low heart rate in cases with delayed onset of post-partum preeclampsia is an important clinical characteristic that may reflect baroreceptors response to maternal hypertension.

Optimal management of post-discharge postpartum hypertensive disorders of pregnancy: a quality improvement initiative

Introduction: Postpartum hypertensive disorders of pregnancy occur in 2-5% of pregnancies. It is a major cause of urgent postpartum consultation and is associated with life-threatening complications. Our objective was to evaluate if local management of postpartum hypertensive disorders of pregnancy was congruent with expert recommendations. Methods: We conducted a quality improvement initiative through a retrospective single-centre cross-sectional study. All women over 18-year-old consulting emergently for hypertensive disorders of pregnancy in the first six weeks postpartum, from 2015 to 2020, were eligible. Results: We included 224 women. Optimal management of postpartum hypertensive disorders of pregnancy was observed in 65.0%. While diagnosis and laboratory work-up were excellent, adequate blood pressure surveillance and recommendations upon discharge of an outpatient postpartum episode (69.7%) did not meet expectations. Conclusion: Efforts should be targeted to improve discharge recommendations on optimal blood pressure surveillance after delivery for women at risk for hypertensive disorders of pregnancy and for postpartum hypertensive disorders of pregnancy in women treated as outpatients.

A novel approach to joint prediction of preeclampsia and delivery timing using semicompeting risks

BACKGROUND

Preeclampsia is a pregnancy complication that contributes substantially to perinatal morbidity and mortality worldwide. Existing approaches to modeling and prediction of preeclampsia typically focus either on predicting preeclampsia risk alone, or on the timing of delivery following a diagnosis of preeclampsia. As such, they are misaligned with typical healthcare interactions during which the 2 events are generally considered simultaneously.

OBJECTIVE

This study aimed to describe the "semicompeting risks" framework as an innovative approach for jointly modeling the risk and timing of preeclampsia and the timing of delivery simultaneously. Through this approach, one can obtain, at any point during the pregnancy, clinically relevant summaries of an individual's predicted outcome trajectories in 4 risk categories: not developing preeclampsia and not having delivered, not developing preeclampsia but having delivered because of other causes, developing preeclampsia but not having delivered, and developing preeclampsia and having delivered.

STUDY DESIGN

To illustrate the semicompeting risks methodology, we presented an example analysis of a pregnancy cohort from the electronic health record of an urban, academic medical center in Boston, Massachusetts (n=9161 pregnancies). We fit an illness-death model with proportional-hazards regression specifications describing 3 hazards for timings of preeclampsia, delivery in the absence of preeclampsia, and delivery following preeclampsia diagnosis.

RESULTS

The results indicated nuanced relationships between a variety of risk factors and the timings of preeclampsia diagnosis and delivery, including maternal age, race/ethnicity, parity, body mass index, diabetes mellitus, chronic hypertension, cigarette use, and proteinuria at 20 weeks' gestation. Sample predictions for a diverse set of individuals highlighted differences in projected outcome trajectories with regard to preeclampsia risk and timing, and timing of delivery either before or after preeclampsia diagnosis.

CONCLUSION

The semicompeting risks framework enables characterization of the joint risk and timing of preeclampsia and delivery, providing enhanced, meaningful information regarding clinical decision-making throughout the pregnancy.

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.

De Novo Postpartum Hypertension: Incidence and Risk Factors at a Safety-Net Hospital

BACKGROUND

Postpartum hypertension can be persistent, following a pregnancy complicated by hypertension, or new onset (de novo), following a normotensive pregnancy. The aim of this study is to estimate the incidence and identify risk factors for de novo postpartum hypertension (dn-PPHTN) among a diverse safety-net hospital population.

METHODS

We conducted a retrospective cohort study of 3925 deliveries from 2016 to 2018. All blood pressure (BP) measures during pregnancy through 12 months postpartum were extracted from medical records. Patients with chronic hypertension or hypertensive disorders of pregnancy were excluded. dn-PPHTN was defined as 2 separate BP readings with systolic BP ≥140 mm Hg and diastolic BP ≥90 mm Hg at least 48 hours after delivery. Severe dn-PPHTN was defined as systolic BP ≥160 and diastolic BP ≥110. We examined risk factors individually and in combination and timing of diagnosis.

RESULTS

Among the 2465 patients without a history of hypertension, 12.1% (n=298) developed dn-PPHTN; 17.1% of whom had severe dn-PPHTN (n=51). Compared to those without dn-PPHTN; cases were more likely to be ≥35 years, delivered via cesarean, or be current or former smokers. Patients with all of these characteristics had a 29% risk of developing dn-PPHTN, which was elevated among non-Hispanic Black patients (36%). Approximately 22% of cases were diagnosed after 6 weeks postpartum.

CONCLUSIONS

More than 1 in 10 patients with normotensive pregnancies experience dn-PPHTN in the year after delivery. Opportunities to monitor and manage patients at the highest risk of dn-PPHTN throughout the entire year postpartum could mitigate cardiovascular related maternal morbidity.

Readmission for postpartum eclampsia in the United States

OBJECTIVE

To characterize the contemporary prevalence of eclampsia in the United States and determine whether eclampsia is taking place during the delivery hospitalization or a postpartum readmission.

STUDY DESIGN

We conducted a retrospective cohort using the 2016 Nationwide Readmission Database, a discharge database of all hospitalizations in 27 states in the U.S. Through the database, we identified women with an admission for delivery of a neonate > 20 weeks gestation. We also identified readmissions that occurred within 6 weeks after discharge from that delivery admission. ICD-10-CM codes were used to identify deliveries, eclampsia and co-morbidities. The primary outcome was timing of eclampsia relative to discharge from the delivery admission.

RESULTS

We identified 1,590,563 deliveries of which 2955 (0.19%) were complicated by eclampsia during the delivery admission or a postpartum readmission. Of these cases of eclampsia, 1575 (53.5%) occurred during the delivery admission, 1354 (45.8%) during a postpartum readmission and 26 (0.88%) during both the delivery and a postpartum readmission. Of the 1380 readmissions with eclampsia, 1117 (81%) occurred within the first week after delivery discharge. Another 194 (14%) occurred in the second week after discharge. Women with readmissions for eclampsia were older (30.1 vs. 28.8 years; p < .01), delivered earlier (37.7 vs. 38.5 weeks; p < .01), and more likely to have a cesarean delivery (48.4 vs. 32.4%; p < .01) or multiple gestation (4.0 vs. 1.8%; p < .01) as compared to those not readmitted for eclampsia and 44% had any hypertensive disorder during the delivery admission (vs. 12.2% without an eclampsia readmission; p < .01).

CONCLUSION

Of the 2955 cases of eclampsia identified, almost half of them occurred after discharge from the delivery admission, 95% of which occurred within the first 2 weeks after discharge, demonstrating the prominence of postpartum eclampsia which may warrant new strategies for prevention and education targeted at postpartum patients after delivery hospitalization.

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.

The Impact of Preeclampsia in Lupus Nephritis

INTRODUCTION

Women with systemic lupus erythematosus (SLE), particularly those with lupus nephritis (LN), remain at high risk for adverse pregnancy outcome. Although in the last decades maternal and fetal outcomes have improved dramatically, preeclampsia remains a major cause of maternal and perinatal morbidity and mortality.

AREAS COVERED

A narrative review of literature was conducted, underlying the importance of pre-conception counseling, and focusing on the correlation between preeclampsia and LN. The clinical characteristics of preeclampsia were described, with emphasis on risk factors in LN and the differential diagnosis between preeclampsia and lupus flares. Additionally, the prevention and treatment of preeclampsia were discussed, as well as the management of short-term and long-term consequences of preeclampsia. We highlight the importance of a pre-pregnancy counseling from a multidisciplinary team to plan pregnancy during inactive SLE and LN.

EXPERT OPINION

Further studies are needed to evaluate the long-term consequences of pregnancy in LN. Considering that preeclamptic patients can be at high risk for long-term renal failure, we suggest renal checkup for at least 6-12 months after delivery in all patients.

Implementation of a universal postpartum blood pressure monitoring program: feasibility and outcomes

BACKGROUND

New-onset postpartum preeclampsia has a higher risk of maternal morbidity and mortality than preeclampsia with antepartum onset, underscoring the need for earlier identification of elevated blood pressure among patients with this condition. Given the decrease in healthcare engagement, which is typical of the postpartum period, new-onset postpartum hypertension often goes unrecognized. Currently, there are no recommendations for universal postpartum blood pressure surveillance in women without hypertensive disorders of pregnancy. With the shift to telemedicine because of the COVID-19 pandemic, our institution's approach was to distribute blood pressure cuffs to women receiving any portion of their prenatal care virtually, thus also providing access to an opportunity for blood pressure measurement during the postpartum period for all women.

OBJECTIVE

To explore the feasibility of a patient-driven universal postpartum home blood pressure monitoring program in women without a previous diagnosis of a hypertensive disorder.

STUDY DESIGN

This was a prospective observational study of all postpartum women who were discharged from our institution from July 2020 through June 2021 and who were not previously identified to have hypertension. A clinical algorithm was developed and followed. All the women received discharge educational materials and were called at a 1-week interval by a nurse to review blood pressure and preeclampsia symptoms. The maternal demographics and delivery outcomes were recorded.

RESULTS

Of the 10,092 deliveries during the study period, 5959 (59%) were successfully contacted. 352 were excluded, as they did not deliver at the primary hospital; 1052 (18%) had a previous hypertensive disorder of pregnancy diagnosis; 1522 (26%) did not have a blood pressure cuff; and 1841 (31%) planned to take their blood pressure at a later time. Precautions and blood pressure parameters were given to this last group. Of the remaining 1192, 222 (19%) had an initial elevated blood pressure. Of these, 98 had a second elevated blood pressure on recheck; 17 were referred to the emergency room for evaluation, with 8 being diagnosed with severe preeclampsia; and the remainder were recommended to follow with their obstetrical provider and enrolled in our institution's remote blood pressure management program. Of the 1192 women, 8% potentially had a new diagnosis of a hypertensive disorder of pregnancy, with 0.7% having severe hypertension. Women with elevated blood pressures were more likely to be of non-Hispanic Black race and have a higher early pregnancy body mass index than those without elevated blood pressures.

CONCLUSION

Our study indicates that a patient-driven postpartum blood pressure monitoring program is feasible and may be incorporated using existing resources. In addition, our findings suggest that the incidence of new-onset postpartum hypertensive disorders of pregnancy may be higher than previously assessed in retrospective cohorts. Thus, there may be a role for closer surveillance of all women with patient-driven home blood pressure monitoring, particularly those with risk factors or in the setting of limited resources.

Hypertensive Disorders of Pregnancy: Common Clinical Conundrums

Importance

Hypertensive complications of pregnancy comprise 16% of maternal deaths in developed countries and 7.4% of deaths in the United States. Rates of preeclampsia increased 25% from 1987 to 2004, and rates of severe preeclampsia have increased 6.7-fold between 1980 and 2003.

Objective

The aim of this study was to review current and available evidence for common clinical questions regarding the management of hypertensive disorders of pregnancy.

Evidence Acquisition

Original research articles, review articles, and guidelines on hypertension in pregnancy were reviewed.

Results

Severe gestational hypertension should be managed as preeclampsia with severe features. Serum uric acid levels can be useful in predicting development of superimposed preeclampsia for women with chronic hypertension. When presenting with preeclampsia with severe features before 34 weeks, expectant management should be considered only when both maternal and fetal conditions are stable. In the setting of hypertensive disorders of pregnancy, oral antihypertensive medications should be initiated when systolic blood pressure is greater than 160 mm Hg or when diastolic blood pressure is greater than 110 mm Hg, with the most ideal agents being labetalol or nifedipine. Furthermore, although risk of preeclampsia recurrence in future pregnancy is low, women with a history of preeclampsia should be managed with 81 mg aspirin daily for preeclampsia prevention.

Conclusions and Relevance

Despite the frequency with which hypertensive disorders of pregnancy are encountered clinically, situations arise frequently with limited evidence to guide providers in their management. An urgent need exists to better understand this disease to optimize outcomes for impacted patients.

Timing of maternal mortality and severe morbidity during the postpartum period

Objective:

The objective of this review was to determine the timing of overall and cause-specific maternal mortality and severe morbidity during the postpartum period.

Introduction:

Many women continue to die or experience adverse health outcomes in the postpartum period; however, limited work has explored the timing of when women die or present complications during this period globally.

Inclusion criteria:

This review considered studies that reported on women after birth up to 6 weeks postpartum and included data on mortality and/or morbidity on the first day, days 2–7, and days 8–42. Studies that reported solely on high-risk women (eg, those with antenatal or intrapartum complications) were excluded, but mixed population samples were included (eg, low-risk and high-risk women).

Methods:

MEDLINE, Embase, Web of Science, and CINAHL were searched for published studies on December 20, 2019, and searches were updated on May 11, 2021. Critical appraisal was undertaken by 2 independent reviewers using standardized critical appraisal instruments from JBI. Quantitative data were extracted from included studies independently by at least 2 reviewers using a study-specific data extraction form. Quantitative data were pooled, where possible. Identified studies were used to obtain the summary estimate (proportion) for each time point. Maternal mortality was calculated as the maternal deaths during a given period over the total number of maternal deaths known during the postpartum period. For cause-specific analysis, number of deaths due to a specific cause was the numerator, while the total number of women who died due to the same cause in that period was the denominator. Random effects models were run to pool incidence proportion for relative risk of overall maternal deaths. Subgroup analysis was conducted according to country income classification and by date (ie, data collection before or after 2010). Where statistical pooling was not possible, the findings were reported narratively.

Results:

A total of 32 studies reported on maternal outcomes from 17 reports, all reporting on mixed populations. Most maternal deaths occurred on the first day (48.9%), with 24.5% of deaths occurring between days 2 and 7, and 24.9% occurring between days 8 and 42. Maternal mortality due to postpartum hemorrhage and embolism occurred predominantly on the first day (79.1% and 58.2%, respectively). Most deaths due to postpartum eclampsia and hypertensive disorders occurred within the first week (44.3% on day 1 and 37.1% on days 2–7). Most deaths due to infection occurred between days 8 and 42 (61.3%). Due to heterogeneity, maternal morbidity data are described narratively, with morbidity predominantly occurring within the first 2 weeks. The mean critical appraisal score across all included studies was 85.9% (standard deviation = 13.6%).

Conclusion:

Women experience mortality throughout the entire postpartum period, with the highest mortality rate on the first day. Access to high-quality care during the postpartum period, including enhanced frequency and quality of postpartum assessments during the first 42 days after birth, is essential to improving maternal outcomes and to continue reducing maternal mortality and morbidity worldwide.

Systematic review registration number:

PROSPERO CRD42020187341

Hematobiochemical variability and predictors of new-onset and persistent postpartum preeclampsia

Preeclampsia (PE) can occur antepartum or postpartum. When it develops de novo after childbirth, it is termed new-onset postpartum PE (NOPPE). Often, antepartum PE disappears after childbirth; however, in some women it persists after childbirth. This form of PE is termed persistent PE (PPE). Thus, there are two forms of postpartum PE: NOPPE and PPE. The pathogenesis and pathophysiology of these diseases have not been fully characterized, and whether NOPPE and PPE are different or similar pathological conditions remains unexplored. Thus, we aimed to compare the haematological and biochemical characteristics of NOPPE and PPE, predict the occurrence of new-onset PE and identify lifestyles that predispose women to postpartum PE. A total of 130 women comprising 65 normotensive postpartum women, 33 NOPPE and 32 PPE women were recruited for this hospital-based case-control study. The socio-demographic and lifestyle characteristics of the participants were obtained through well-structured questionnaires. Haematological and biochemical indices were measured using automated analysers and ELISA. The prevalence of postpartum PE was 11.9%. Dyslipidaemia (p =  < 0.0001), hypomagnesaemia (p =  < 0.001), elevated serum levels of ALT, AST (p =  < 0.0001), sVCAM-1 (p =  < 0.0001) and sFlt-1 (p =  < 0.0001) were more prevalent and severe in the PPE than in the NOPPE. Sedentary lifestyle was common among both groups of hypertensive women. Elevated ALT and AST were significant predictors of NOPPE. These findings indicate that preeclampsia exists after childbirth in a high percentage of women. NOPPE and PPE are different pathological conditions that require different clinical management. Combined glucose, lipid and liver assessment could be useful in predicting postpartum PE.

Does race or ethnicity play a role in the origin, pathophysiology, and outcomes of preeclampsia? An expert review of the literature

The burden of preeclampsia, a substantial contributor to perinatal morbidity and mortality, is not born equally across the population. Although the prevalence of preeclampsia has been reported to be 3% to 5%, racial and ethnic minority groups such as non-Hispanic Black women and American Indian or Alaskan Native women are widely reported to be disproportionately affected by preeclampsia. However, studies that add clarity to the causes of the racial and ethnic differences in preeclampsia are limited. Race is a social construct, is often self-assigned, is variable across settings, and fails to account for subgroups. Studies of the genetic structure of human populations continue to find more variations within racial groups than among them. Efforts to examine the role of race and ethnicity in biomedical research should consider these limitations and not use it as a biological construct. Furthermore, the use of race in decision making in clinical settings may worsen the disparity in health outcomes. Most of the existing data on disparities examine the differences between White and non-Hispanic Black women. Fewer studies have enough sample size to evaluate the outcomes in the Asian, American Indian or Alaskan Native, or mixed-race women. Racial differences are noted in the occurrence, presentation, and short-term and long-term outcomes of preeclampsia. Well-established clinical risk factors for preeclampsia such as obesity, diabetes, and chronic hypertension disproportionately affect non-Hispanic Black, American Indian or Alaskan Native, and Hispanic populations. However, with comparable clinical risk factors for preeclampsia among women of different race or ethnic groups, addressing modifiable risk factors has not been found to have the same protective effect for all women. Abnormalities of placental formation and development, immunologic factors, vascular changes, and inflammation have all been identified as contributing to the pathophysiology of preeclampsia. Few studies have examined race and the pathophysiology of preeclampsia. Despite attempts, a genetic basis for the disease has not been identified. A number of genetic variants, including apolipoprotein L1, have been identified as possible risk modifiers. Few studies have examined race and prevention of preeclampsia. Although low-dose aspirin for the prevention of preeclampsia is recommended by the US Preventive Service Task Force, a population-based study found racial and ethnic differences in preeclampsia recurrence after the implementation of low-dose aspirin supplementation. After implementation, recurrent preeclampsia reduced among Hispanic women (76.4% vs 49.6%; P<.001), but there was no difference in the recurrent preeclampsia in non-Hispanic Black women (13.7 vs 18.1; P=.252). Future research incorporating the National Institute on Minority Health and Health Disparities multilevel framework, specifically examining the role of racism on the burden of the disease, may help in the quest for effective strategies to reduce the disproportionate burden of preeclampsia on a minority population. In this model, a multilevel framework provides a more comprehensive approach and takes into account the influence of behavioral factors, environmental factors, and healthcare systems, not just on the individual.

Postpartum preeclampsia or eclampsia: defining its place and management among the hypertensive disorders of pregnancy

High blood pressure in the postpartum period is most commonly seen in women with antenatal hypertensive disorders, but it can develop de novo in the postpartum time frame. Whether postpartum preeclampsia or eclampsia represents a separate entity from preeclampsia or eclampsia with antepartum onset is unclear. Although definitions vary, the diagnosis of postpartum preeclampsia should be considered in women with new-onset hypertension 48 hours to 6 weeks after delivery. New-onset postpartum preeclampsia is an understudied disease entity with few evidence-based guidelines to guide diagnosis and management. We propose that new-onset hypertension with the presence of any severe features (including severely elevated blood pressure in women with no history of hypertension) be referred to as postpartum preeclampsia after exclusion of other etiologies to facilitate recognition and timely management. Older maternal age, black race, maternal obesity, and cesarean delivery are all associated with a higher risk of postpartum preeclampsia. Most women with delayed-onset postpartum preeclampsia present within the first 7 to 10 days after delivery, most frequently with neurologic symptoms, typically headache. The cornerstones of treatment include the use of antihypertensive agents, magnesium, and diuresis. Postpartum preeclampsia may be associated with a higher risk of maternal morbidity than preeclampsia with antepartum onset, yet it remains an understudied disease process. Future research should focus on the pathophysiology and specific risk factors. A better understanding is imperative for patient care and counseling and anticipatory guidance before hospital discharge and is important for the reduction of maternal morbidity and mortality in the postpartum period.

Manipulating CD4+ T Cell Pathways to Prevent Preeclampsia

Preeclampsia (PreE) is a placental disorder characterized by hypertension (HTN), proteinuria, and oxidative stress. Individuals with PreE and their children are at an increased risk of serious short- and long-term complications, such as cardiovascular disease, end-organ failure, HTN, neurodevelopmental disorders, and more. Currently, delivery is the only cure for PreE, which remains a leading cause of morbidity and mortality among pregnant individuals and neonates. There is evidence that an imbalance favoring a pro-inflammatory CD4+ T cell milieu is associated with the inadequate spiral artery remodeling and subsequent oxidative stress that prime PreE's clinical symptoms. Immunomodulatory therapies targeting CD4+ T cell mechanisms have been investigated for other immune-mediated inflammatory diseases, and the application of these prevention tactics to PreE is promising, as we review here. These immunomodulatory therapies may, among other things, decrease tumor necrosis factor alpha (TNF-α), cytolytic natural killer cells, reduce pro-inflammatory cytokine production [e.g. interleukin (IL)-17 and IL-6], stimulate regulatory T cells (Tregs), inhibit type 1 and 17 T helper cells, prevent inappropriate dendritic cell maturation, and induce anti-inflammatory cytokine action [e.g. IL-10, Interferon gamma (IFN-γ)]. We review therapies including neutralizing monoclonal antibodies against TNF-α, IL-17, IL-6, and CD28; statins; 17-hydroxyprogesterone caproate, a synthetic hormone; adoptive exogenous Treg therapy; and endothelin-1 pathway inhibitors. Rebalancing the maternal inflammatory milieu may allow for proper spiral artery invasion, placentation, and maternal tolerance of foreign fetal/paternal antigens, thereby combatting early PreE pathogenesis.

Risk factors for the development of new-onset and persistent postpartum preeclampsia: A case–control study in Ghana

Background:

Postpartum preeclampsia has been implicated in increasing hospital re-admissions, maternal morbidity, and mortality worldwide. The knowledge of the risk factors of postpartum preeclampsia would be helpful in formulating strategies to aid in the prevention, early diagnosis, and timely treatment of this disorder. Thus, this study aimed to identify the risk factors associated with the development of new-onset postpartum preeclampsia and persistent postpartum preeclampsia in the Ghanaian setting.

Methods:

This case–control study was conducted at the Obstetrics and Gynecology units of Komfo Anokye Teaching Hospital and the Kumasi Regional Hospital, both located in the Ashanti Region of Ghana. A total of 65 postpartum preeclamptic women (33 new-onset postpartum preeclampsia and 32 persistent postpartum preeclampsia) and 65 normotensive postpartum mothers were recruited from 48 h to 6 weeks post-delivery. Questionnaires were administered to assess the socio-demographic, lifestyle, obstetric characteristics, and past medical history of the study participants.

Results:

Physical inactivity (p < 0.0001), infrequent antenatal visits (p < 0.0001), analgesic use (p < 0.0001), and cesarean delivery (p = 0.021) were significantly associated with both the new-onset postpartum preeclampsia and persistent postpartum preeclampsia. Contraceptive use was significantly associated with the development of new-onset postpartum preeclampsia (p < 0.0001) while women with low-birthweight babies are also at high risk of developing persistent postpartum preeclampsia (p < 0.0001).

Conclusion:

Physical inactivity, infrequent antenatal visits, analgesic use, contraceptive use, and cesarean delivery are major predisposing risk factors for the development of postpartum preeclampsia. Screening using these risk factors, close monitoring and follow-up observation of women after delivery would be beneficial in identifying and managing postpartum preeclampsia.

Prenatal antidepressant use and the implication of hypertensive disorders during pregnancy

BACKGROUND

Evidence for the association between prenatal antidepressant use and the development of hypertensive disorders of pregnancy is inconsistent. Previous studies have reported that antidepressant use during pregnancy increases the risk for gestational hypertension and preeclampsia, but the results of these studies are potentially confounded by important methodologic limitations. Furthermore, it remains unknown whether a higher cumulative dose of antidepressant increases the risk for hypertensive disorders of pregnancy.

OBJECTIVE

This study aimed to investigate the association between prenatal antidepressant use and the risk for hypertensive disorders of pregnancy and the potential effect of a higher cumulative antidepressant dose.

STUDY DESIGN

This retrospective cohort study used data from the Health and Welfare Database in Taiwan. Pregnant women with depression aged 18 to 49 years were enrolled as part of the study population. Prenatal antidepressant use was defined as at least 1 dispensing record of an antidepressant between the conception date and 20 weeks of gestation. Antidepressant users were further divided into groups according to the cumulative defined daily dose based on whether they took the defined daily dose for ≤10 weeks (low cumulative dose group ≤70 cumulative defined daily dose) or for >10 weeks (high cumulative dose group >70 cumulative defined daily dose). The primary outcome was hypertensive disorders of pregnancy defined as the diagnosis of either gestational hypertension or preeclampsia during the period from 20 weeks of gestation to delivery. Propensity score matching and stabilized inverse probability of treatment weighting were used to balance the confounders between the comparison groups. A robust Cox regression model was used to evaluate the association between exposure and outcome.

RESULTS

A total of 5664 pregnant women with depression were included in the study (2832 antidepressant users matched to 2832 antidepressant nonusers). Prenatal antidepressant use was not associated with an increased risk for hypertensive disorders of pregnancy (adjusted hazard ratio, 0.89; 95% confidence interval, 0.67-1.18). However, among antidepressant users, the risk for hypertensive disorders of pregnancy was higher among women with a higher cumulative defined daily dose than among women with a lower cumulative defined daily dose (adjusted hazard ratio, 2.46; 95% confidence interval, 1.05-5.74).

CONCLUSION

No association was found between antidepressant use and the development of hypertensive disorders of pregnancy. However, women taking higher cumulative doses of antidepressants were at greater risk. More frequent or regular monitoring of blood pressure may be warranted in women on high cumulative doses of antidepressants.

Atypical hemolytic uremic syndrome: when pregnancy leads to lifelong dialysis: a case report and literature review

Atypical hemolytic uremic syndrome (aHUS), a challenging disorder, commonly caused by inherited defects or regulatory processes of the complement alternative pathway. There are multiple causes, including pregnancy. Pregnancy provokes life-threatening episodes, preeclampsia, hemolysis elevated liver enzymes low platelets, microangiopathic hemolytic anemia (MAHA) and end-stage renal disease. Additionally, complement dysregulation and, with aHUS, affects fetal and maternal outcomes. Pregnancy-associated aHUS results in a poor prognosis with irreversible renal damage. Likewise, it is imperative to know that MAHA can provoke endothelial disruption, destruction of red cells and thrombocytopenia. We present a case of a young 18-year-old woman with MAHA and aHUS, requiring emergent cesarean section at 34 weeks of gestation and hemodialysis, secondary to complications from a recent pregnancy. Elevated blood pressure readings, rising creatinine levels, as well as her mother being on dialysis after pregnancy raised suspicion for thrombotic microangiopathy and aHUS. She was subsequently managed with plasma exchange, steroids, eculizumab and hemodialysis. Thus, plasma exchange should be initiated, with pending additional workup. Upon a definitive diagnosis of aHUS, eculizumab would be warranted to mitigate immune dysregulation. Understanding thrombotic microangiopathies diagnosis, and recognizing concomitant consequences, is vital. Having better insights into endothelial injuries can prevent unfortunate outcomes.

Incidence and risk factors for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia at preterm and term gestation: a population-based study

BACKGROUND

The majority of previous studies on severe preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome were hospital-based or included a relatively small number of women. Large, population-based studies examining gestational age-specific incidence patterns and risk factors for these severe pregnancy complications are lacking.

OBJECTIVE

This study aimed to assess the gestational age-specific incidence rates and risk factors for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia.

STUDY DESIGN

We carried out a retrospective, population-based cohort study that included all women with a singleton hospital birth in Canada (excluding Quebec) from 2012 to 2016 (N=1,078,323). Data on the primary outcomes (ie, severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia) were obtained from delivery hospitalization records abstracted by the Canadian Institute for Health Information. A Cox regression was used to assess independent risk factors (eg, maternal age and chronic comorbidity) for each primary outcome and to assess differences in the effects at preterm vs term gestation (<37 vs ≥37 weeks).

RESULTS

The rates of severe preeclampsia (n=2533), hemolysis, elevated liver enzymes, and low platelet count syndrome (n=2663), and eclampsia (n=465) were 2.35, 2.47, and 0.43 per 1000 singleton pregnancies, respectively. The cumulative incidence of term-onset severe preeclampsia was lower than that of preterm-onset severe preeclampsia (0.87 vs 1.54 per 1000; rate ratio, 0.57; 95% confidence intervals, 0.53-0.62), the rates of hemolysis, elevated liver enzymes, and low platelet count syndrome were similar (1.32 vs 1.23 per 1000; rate ratio, 0.93; 95% confidence interval, 0.86-1.00), and the preterm-onset eclampsia rate was lower than the term-onset rate (0.12 vs 0.33 per 1000; rate ratio, 2.64; 95% confidence interval, 2.16-3.23). For each primary outcome, chronic comorbidity and congenital anomalies were stronger risk factors for preterm- vs term-onset disease. Younger mothers (aged <25 years) were at higher risk for severe preeclampsia at term and for eclampsia at all gestational ages, whereas older mothers (aged ≥35 years) had elevated risks for severe preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome. Regardless of gestational age, nulliparity was a risk factor for all outcomes, whereas socioeconomic status was inversely associated with severe preeclampsia.

CONCLUSION

The risk for severe preeclampsia declined at term, eclampsia risk increased at term, and hemolysis, elevated liver enzymes, and low platelet count syndrome risk was similar for preterm and term gestation. Young maternal age was associated with an increased risk for eclampsia and term-onset severe preeclampsia. Prepregnancy comorbidity and fetal congenital anomalies were more strongly associated with severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia at preterm gestation.

Racial Disparity in Postpartum Readmission due to Hypertension among Women with Pregnancy-Associated Hypertension

OBJECTIVE

Postpartum hypertension is a leading cause of readmission in the postpartum period. We aimed to examine the prevalence of racial/ethnic differences in postpartum readmission due to hypertension in women with antepartum pregnancy-associated hypertension.

STUDY DESIGN

This was a multi-institutional retrospective cohort study of all women with antepartum pregnancy-associated hypertension diagnosed prior to initial discharge from January 2009 to December 2016. Antepartum pregnancy-associated hypertension, such as gestational hypertension, preeclampsia (with or without severe features), hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome, and eclampsia was diagnosed based on American College of Obstetricians and Gynecologists Task Force definitions. Women with chronic hypertension and superimposed preeclampsia were excluded. Our primary outcome was postpartum readmission defined as a readmission due to severe hypertension within 6 weeks of postpartum. Risk factors including maternal age, gestational age at admission, insurance, race/ethnicity (self-reported), type of antepartum pregnancy-associated hypertension, marital status, body mass index (kg/m²), diabetes (gestational or pregestational), use of antihypertensive medications, mode of delivery, and postpartum day 1 systolic blood pressure levels were examined. Multivariable logistic regression models were performed to calculate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).

RESULTS

Of 4,317 women with pregnancy-associated hypertension before initial discharge, 66 (1.5%) had postpartum readmission due to hypertension. Risk factors associated with postpartum readmission due to hypertension included older maternal age (aOR = 1.44; 95% CI: 1.20-1.73 for every 5 year increase) and non-Hispanic black race (aOR = 2.12; 95% CI: 1.16-3.87).

CONCLUSION

In women with pregnancy-associated hypertension before initial discharge, non-Hispanic black women were at increased odds of postpartum readmission due to hypertension compared with non-Hispanic white women.

Predictors of readmission for postpartum preeclampsia

Objective: To develop a predictive model for re-admission for postpartum preeclampsia (PPEC).Methods: A case-control study; cases were patients re-admitted for PPEC; controls were not re-admitted. Mixed linear modelling was used to develop a predictive model on the training set, then validated on the validation set.Results: Two-hundred-sixty-nine patients were readmitted, and matched to 538 controls. A risk calculator was developed and yielded a sensitivity and specificity for readmission of 80.9% and 53.5%, respectively.Conclusion: A predictive model using age, race, discharge blood pressures, and preeclampsia was able to predict re-admission for PPEC with a high level of sensitivity.

New-onset postpartum preeclampsia: epigenetic mechanism and prediction

OBJECTIVE

Placental cytosine (CpG) methylation was measured to predict new-onset postpartum preeclampsia (NOPP) and interrogate its molecular pathogenesis.

METHODS

NOPP was defined as patients with a new diagnosis of postpartum preeclampsia developing ≥48 h to ≤6 weeks after delivery with no prior hypertensive disorders. Placental tissue was obtained from 12 NOPP cases and 12 normotensive controls. Genome-wide individual cytosine (CpG) methylation level was measured with the Infinium MethylationEPIC BeadChip array. Significant differential methylation (NOPP vs. controls) for individual CpG loci was defined as false discovery rate (FDR) p value <.05. Gene functional enrichment using Qiagen's ingenuity pathway analysis (IPA) was performed to help elucidate the molecular pathogenesis of NOPP. A logistic regression model for NOPP prediction based on the methylation level in a combination of CpG loci was generated. The area under the receiver operating characteristic curves (AUC [95% CI]) sensitivity, and specificity for NOPP prediction based on the CpG methylation level was calculated for each locus.

RESULTS

There were 537 (in 540 separate genes) significantly (FDR p<.05 with a ≥ 2.0-fold methylation difference) differentially methylated CpG loci between the groups. A total of 143 individual CpG markers had excellent individual predictive accuracy for NOPP prediction (AUC ≥0.80), of which 14 markers had outstanding accuracy (AUC ≥0.90). A logistic regression model based on five CpG markers yielded an AUC (95% CI)=0.99 (0.95-0.99) with sensitivity 95% and specificity 93% for NOPP prediction. IPA revealed dysregulation of critical pathways (e.g., angiogenesis, chronic inflammation, and epithelial-mesenchymal transition) known to be linked to classic preeclampsia, in addition to other previously undescribed genes/pathways.

CONCLUSIONS

There was significant placental epigenetic dysregulation in NOPP. NOPP shared both common and unique molecular pathways with classic preeclampsia. Finally, we have identified novel potential biomarkers for the early post-partum prediction of NOPP.

Magnetic Resonance Imaging in Peripartum Encephalopathy: A Pictorial Review

Acute neurological problems are significant disorders of pre- and postpartum period in women. We analyzed the magnetic resonance imaging (MRI) profile of patients presenting with peripartum encephalopathy over 2 years. Of 51 patients, MRI was abnormal in 40 patients and normal in 11 patients. Posterior reversible encephalopathy (13/40), cerebral venous thrombosis (6/40), and postpartum angiopathy (3/40) are the three most common causes of peripartum encephalopathy as identified in MRI. The other less common but important etiology include HELLP (Hemolysis, Elevated Liver enzymes and Low Platelet) syndrome (2), osmotic demyelination (2), antiphospholipid syndrome (2), tubercular meningitis/cerebritis (3), pituitary hyperplasia with hemorrhage (2), postictal edema (2), cerebellitis (1), transient splenial lesion (1), and changes of old trauma and stroke (one each).

Neurology of Preeclampsia and Related Disorders: an Update in Neuro-obstetrics

PURPOSE OF REVIEW

Preeclampsia and related hypertensive disorders of pregnancy affect up to 10% of pregnancies. Neurological complications are common and neurologists often become involved in the care of obstetric patients with preeclampsia. Here, we review the definition(s), epidemiology, clinical features, and pathophysiology of preeclampsia, focusing on maternal neurological complications and headache as a common presenting symptom of preeclampsia.

RECENT FINDINGS

Neurological symptoms are early and disease-defining features of preeclampsia. Neurological complications of preeclampsia may include headaches, visual symptoms, cerebral edema, seizures, or acute cerebrovascular disorders such as intracerebral hemorrhage or reversible cerebral vasoconstriction syndrome. A history of migraine is an independent risk factor for vascular diseases during pregnancy, including preeclampsia and maternal stroke. The pathophysiology of both preeclampsia and migraine is complex, and the mechanisms linking the two are not fully understood. Overlapping clinical and pathophysiological features of migraine and preeclampsia include inflammation, vascular endothelial dysfunction, and changes in vasoreactivity. Neurological complications are recognized as a major contributor to maternal morbidity and mortality. Pregnant and postpartum women commonly present with headache, and red flags in the clinical history and examination should prompt urgent neuroimaging and laboratory evaluation. A focused headache history should be elicited from patients as part of routine obstetrical care to identify patients at an increased risk of preeclampsia and related hypertensive disorders of pregnancy. Collaborative models of care and scientific investigation in the emerging field of neuro-obstetrics have the common goal of reducing the risk of maternal neurological morbidity and mortality from preeclampsia.

Postpartum complications increased in women with polycystic ovary syndrome

BACKGROUND

Women with polycystic ovary syndrome are at a higher risk of cardiometabolic and psychiatric comorbidities and preconception and antepartum complications, but the impact of polycystic ovary syndrome during the postpartum period is unknown.

OBJECTIVE

This study aimed to investigate the risk of postpartum cardiovascular disease complications and perinatal and postpartum depression.

STUDY DESIGN

This was a retrospective cohort study conducted using a United States insurance claims database. Women with and without polycystic ovary syndrome aged 18 to 50 years enrolled continuously in a single health plan during the preconception, antepartum, and postpartum periods between 2000 and 2016 were included. The primary outcome was postpartum cardiovascular disease and depression (perinatal and postpartum). Multivariable logistic regression was used to adjust for covariates including age, geographic location, preterm delivery, assisted reproductive technology use, multiple births, prepregnancy depression, prepregnancy diabetes, prepregnancy hypertension, gestational diabetes, gestational hypertension, obesity, history of hyperlipidemia, smoking, and race.

RESULTS

We identified 42,391 unique women with polycystic ovary syndrome and 795,480 women without polycystic ovary syndrome. In multivariable models, women with polycystic ovary syndrome had significantly higher odds of cardiovascular disease complications, including postpartum preeclampsia (adjusted odds ratio, 1.30; 95% confidence interval, 1.17-1.45), eclampsia (adjusted odds ratio, 1.45; 95% confidence interval, 1.14-1.86) cardiomyopathy (adjusted odds ratio, 1.26; 95% confidence interval, 1.03-1.54), hypertensive heart disease (adjusted odds ratio, 1.32: 95% confidence interval, 1.07-1.64), thrombotic disease (adjusted odds ratio, 1.50; 95% confidence interval, 1.20-1.87), congestive heart failure (adjusted odds ratio, 1.35; 95% confidence interval, 1.13-1.61), and cerebrovascular accidents (adjusted odds ratio, 1.21; 95% confidence interval, 1.14-1.29), than those without polycystic ovary syndrome, as well as both perinatal (adjusted odds ratio, 1.27; 95% confidence interval, 1.22-1.33) and postpartum depression (adjusted odds ratio, 1.46; 95% confidence interval, 1.36-1.57). Nonobese women with polycystic ovary syndrome had higher odds of postpartum eclampsia (adjusted odds ratio 1.72; 95% confidence interval, 1.31-2.26), peripartum cardiomyopathy (adjusted odds ratio, 1.43; 95% confidence interval, 1.14-1.79), and cerebrovascular accidents (adjusted odds ratio, 1.28; 95% confidence interval, 1.19-1.38) than nonobese women without polycystic ovary syndrome. In the group of women without prepregnancy depression, the odds of perinatal depression (adjusted odds ratio, 1.32; 95% confidence interval, 1.26-1.39) and postpartum depression (adjusted odds ratio, 1.50; 95% confidence interval, 1.39-1.62) were higher in women with polycystic ovary syndrome than those without polycystic ovary syndrome.

CONCLUSION

In a large United States cohort, our study found that women with polycystic ovary syndrome are at increased risk of both cardiovascular and psychiatric complications during the postpartum period. Polycystic ovary syndrome should be recognized as an at-risk condition; our findings underscore the need for routine screening and early interventions for these major comorbidities.

Risk factors for postpartum readmission for preeclampsia or hypertension before delivery discharge among low-risk women: a case-control study

BACKGROUND

Postpartum hypertension or preeclampsia is one of the most frequent reasons for readmission after delivery discharge, and risk factors for readmission remain poorly characterized.

OBJECTIVE

This study aimed to determine risk factors of postpartum readmission for hypertension or preeclampsia among low-risk women before delivery discharge.

STUDY DESIGN

We conducted a nested case-control study from 2012 to 2015 at a tertiary care medical center. Cases were identified using diagnostic codes for postpartum transient hypertension, mild preeclampsia, severe preeclampsia, eclampsia, superimposed preeclampsia, and unspecified hypertension and readmission within 6 weeks of delivery. Controls not readmitted for hypertension or preeclampsia were time matched within 4 weeks of the delivery date to each case. We fit multivariable logistic regression models to identify independent risk factors for postpartum readmission for hypertension or preeclampsia and then calculated a receiver operating characteristic curve of the final model to assess model discrimination.

RESULTS

Within the source cohort resulting in 58 cases and 232 matched controls, the rate of postpartum readmission for preeclampsia or hypertension was 0.4% (n=58 of 14,503). The median time to readmission was 6 days (range, 2-15 days), and 40% of cases had an outpatient postpartum visit before readmission. In multivariable analysis, non-Hispanic black race (adjusted odds ratio, 2.14; 95% confidence interval, 0.99-4.59), gestational hypertension (adjusted odds ratio, 2.70; 95% confidence interval, 1.12-6.54), preeclampsia during delivery admission (adjusted odds ratio, 3.12; 95% confidence interval, 1.29-7.50), and maximum postpartum systolic blood pressure during delivery admission (adjusted odds ratio, 1.05; 95% confidence interval, 1.03-1.08) were risk factors for readmission. This model had a good discriminative ability to predict women who would require readmission for preeclampsia or hypertension (area under the curve, 0.83; 95% confidence interval, 0.74-0.89). Using these 4 factors to illustrate this model, the predicted risk of readmission ranged from <1% in the lowest risk scenario (eg, postpartum systolic blood pressure of 120 mm Hg + no hypertensive disorders of pregnancy + white race) to 26% in the highest risk scenario (eg, postpartum systolic blood pressure of 160 mm Hg + preeclampsia + black race).

CONCLUSION

Risk factors of postpartum readmission for hypertension or preeclampsia can be identified at the time of delivery discharge among low-risk women, regardless of an antenatal hypertensive disorder. A next step could be using these risk factors to develop a predictive model to guide postpartum care.

Cardiovascular and cerebrovascular health after pre-eclampsia: the Motherhealth prospective cohort study protocol

INTRODUCTION

Cardiovascular and cerebrovascular diseases (CCVDs) are the leading cause of maternal mortality in the first year after delivery. Women whose pregnancies were complicated by pre-eclampsia are at particularly high risk for adverse events. In addition, women with a history of pre-eclampsia have higher risk of CCVD later in life. The physiological mechanisms that contribute to increased CCVD risk in these women are not well understood, and the optimal clinical pathways for postpartum CCVD risk reduction are not yet defined.

METHODS AND ANALYSIS

The Motherhealth Study (MHS) is a prospective cohort study at Columbia University Irving Medical Center (CUIMC), a quaternary care academic medical centre serving a multiethnic population in New York City. MHS began recruitment on 28 September 2018 and will enrol 60 women diagnosed with pre-eclampsia with severe features in the antepartum or postpartum period, and 40 normotensive pregnant women as a comparison cohort. Clinical data, biospecimens and measures of vascular function will be collected from all participants at the time of enrolment. Women in the pre-eclampsia group will complete an additional three postpartum study visits over 12-24 months. Visits will include additional detailed cardiovascular and cerebrovascular phenotyping. As this is an exploratory, observational pilot study, only descriptive statistics are planned. Data will be used to inform power calculations for future planned interventional studies.

ETHICS AND DISSEMINATION

The CUIMC Institutional Review Board approved this study prior to initiation of recruitment. All participants signed informed consent prior to enrolment. Results will be disseminated to the clinical and research community, along with the public, on completion of analyses. Data will be shared on reasonable request.

Hypertensive Disorders of Pregnancy

"Pregnancy-induced hypertension" (HDP) describes a spectrum of disorders, including gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. Each of these disease processes can progress to a more pathologic case with worsening hypertensive disease, end-organ damage, and concerning clinical sequelae. Risk factors for HDP include nulliparity, a prior pregnancy complicated by hypertension, and obesity. Close blood pressure monitoring, serologic and urine testing, and prompt clinical follow-up remain the gold standard for antenatal diagnosis and surveillance. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multidisciplinary team-based approach, and referral to an experienced provider for cases with advanced pathology.