[Consequence of hypertensive disorders during pregnancy (THE) on women's cardiovascular health]

Patients with hypertensive disorders of pregnancy (HDP) are at increased risk of maternal-fetal complications and represent the third leading cause of maternal mortality. To date, it is known that women experiencing this condition during pregnancy have a higher future risk of cardiovascular events (CVD). Our objective was to report the incidence of new-onset hypertension in the postpartum period. We conducted a cohort study in high-risk pregnant patients who underwent ambulatory blood pressure monitoring (ABPM) between weeks 20-30. Patients were categorized as normotensive (NT) or gestational hypertensive (GH), excluding those with chronic hypertension, and were followed until the end of pregnancy with a postpartum assessment after 3months. Patients with HDP (39%) had a higher incidence of preeclampsia and newborns with low birth weight and preterm birth. A total of 177 pregnant women were analyzed for the primary outcome. Among those with GH, 33.3% vs 17.2% of NT (P=.014) reported new-onset hypertension. The odds ratio for developing new-onset hypertension was 2.3 (95%CI: 1.20-4.77), for those with GH. In conclusion, pregnant patients with GH assessed by ABPM between 20-30weeks are at higher risk of developing new-onset hypertension in the postpartum period, emphasizing the need for closer monitoring and control to prevent future cardiovascular complications.

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.

Discharge medication delivery location and postpartum blood pressure control in patients with hypertensive disorders of pregnancy

OBJECTIVE

This study examined whether use of bedside medication delivery (Meds to Beds, M2B) or on-campus pharmacy at discharge was associated with improved postpartum blood pressure (BP) control compared to outside pharmacy use in patients with hypertensive disorders of pregnancy (HDP).

STUDY DESIGN

This was a secondary analysis of 357 patients with HDP enrolled in STAMPP-HTN (Systematic Treatment and Management of Postpartum Hypertension Program) who were discharged from delivery admission with antihypertensives between October 2018 and June 2020. Patients were grouped by discharge medication location: M2B/on-campus pharmacy (on-site) versus outside pharmacy (off-site).

MAIN OUTCOME MEASURES

The primary outcome was BP values at the immediate postpartum visit. Secondary outcomes included six-week visit BP values, attendance at both visits, and readmission within six weeks.

RESULTS

Median BP values were no different based on pharmacy location at immediate postpartum visit for both systolic ((135 [IQR 127, 139] on-site vs 137 [127, 145] off-site, p = 0.22) and diastolic (81 [74, 91] vs 83 [76, 92], p = 0.45) values. Similar findings were noted at six weeks. Patients who used an off-site pharmacy had higher attendance rates at the immediate postpartum visit but this difference was attenuated after adjusting for group differences (OR 0.67 [95 % CI 0.37-1.20], p = 0.18). Readmission rates were also not different between groups (12.2 % on-site vs 15.8 % off-site pharmacy, p = 0.43).

CONCLUSION

In the context of a preexisting multicomponent HDP quality improvement program, on-campus pharmacy and bedside medication delivery use was not associated with additional improvement in postpartum BP control, follow-up rates, or readmission rates.

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 antihypertensive treatment: Is there a correlation to placental lesions?

OBJECTIVE

We aimed to examine the association of clinical risk factors and placental lesions, in gestations complicated with preeclampsia, with the need for antihypertensive treatment in the early postpartum period.

METHODS

The computerized files and placental reports of all singleton deliveries at 24.0-42.0 weeks complicated by preeclampsia were reviewed between January 2013 and October 2020. Obstetric characteristics and placental lesions were compared between patients who required antihypertensive treatment in the early postpartum period and those who did not (control group). Placentas were classified into maternal and fetal malperfusion lesions and inflammatory responses.

RESULTS

As compared to controls (n = 200), the anti-hypertensive treatment group (n = 95) was characterized by increased rates of preterm birth, preeclampsia with severe features, and cesarean delivery (p < 0.001 for all). More placental hematomas (p = 0.01) and placental maternal vascular lesions (p = 0.03) were observed in the antihypertensive treatment group as compared to controls. In adjusted logistic regression analysis, gestational age (OR 0.86, 95% CI 0.79-0.93, p = 0.001) and preeclampsia with severe features (OR 8.89, 95% CI 3.18-14.93 p < 0.001) were found to be independently associated with the need for postpartum antihypertensive treatment.

CONCLUSION

Placental vascular lesions are more common in preeclamptic patients who need postpartum antihypertensive treatment, yet only early onset of preeclampsia with severe features was found to be independently associated with antihypertensive treatment in the early postpartum period.

Self-management system for postpartum women with hypertension disorders: an eHealth application intervention study

BACKGROUND

Hypertension disorders are relatively common in pregnant women and often persist in the postpartum period. Few studies are available regarding the self-management of postpartum hypertension via the eHealth system. This study aimed to develop a self-management eHealth system for women with postpartum hypertension during the postpartum period.

METHODS

We adopted a multi-platform system for this research, not only for use on the web interface but also on smartphones. The proposed system possessed three features: (1) the population was limited to postnatal women with hypertension; (2) a self-care record, which allowed postnatal women to keep track of their blood pressure, pulse, weight, medication record, exercise record, and risk factor assessment; and (3) through this system, nurse-midwives could keep track of postnatal women's health status maintaining the complete record and could communicate directly with the users if their health monitor values reach beyond normal range.

RESULTS

Thirty-nine postnatal women with postpartum hypertension were recruited to the study. A survey to evaluate the usability and satisfaction of the proposed e-health application system was completed by these women. The usability rate of the system reached 92.4% (46.2% satisfied and 46.2% strongly satisfied), which suggested that the system was helpful to the users. The satisfaction rate of the system reached 94.9% (43.6% satisfied and 51.3% strongly satisfied), which suggested that the system was acceptable to the users.

CONCLUSION

This proposed system has been developed completely with user experience and professional advice from experts. Postnatal women could gain important postpartum-related knowledge and access their related health records and other information easily via their smartphones or computers. During the postpartum period, an eHealth application system can effectively assist women with hypertension to manage their blood pressure and related postnatal healthcare issues.

Elimination of Racial Disparities in Postpartum Hypertension Follow-Up After Incorporation of Telehealth into a Quality Bundle

BACKGROUND

Black people have disproportionately higher risk for hypertensive disorders of pregnancy and postpartum complications than White people, but historically lower rates of postpartum follow-up. Few studies have investigated telehealth in the postpartum population.

OBJECTIVES

This study aimed to investigate whether rapid switch to telehealth during the COVID-19 pandemic decreased racial disparities in postpartum hypertension follow-up adherence.

STUDY DESIGN

This retrospective cohort study included all patients with hypertensive disorders of pregnancy who delivered between December 2019 and June 2020 at an urban, tertiary-care center. A preexisting, postpartum hypertension quality improvement initiative was in place at this institution. Follow-up adherence within six weeks postpartum and at the six-week visit were compared prior to February 15, 2020 (pre-telehealth period) and following March 14, 2020 (post-telehealth period), with a one-month implementation/washout period. Blood pressures at these visits were compared between time periods as a secondary outcome.

RESULTS

A total of 473 patients were included in this analysis, of whom 76.3% were Non-Hispanic (NH) Black. There were 215 and 258 patients in the pre- and post-telehealth cohorts, respectively. Among those who attended follow-up, the proportion of visits done over telehealth went from 0% pre-telehealth to 98.0% post-telehealth. The proportion of postpartum hypertension follow-up attendance changed from 48.5% to 76.3% among NH Black people (p<0.0001) and 73.1% to 76.7% among NH White people (p=0.76), leaving only a 0.4% racial gap (p = 0.97) resulting in an elimination of the racial disparity in the post-telehealth period.

CONCLUSION

Transition to telehealth with audio-based visits at the onset of the COVID-19 pandemic improved attendance at postpartum hypertension visits amongst NH Black people and therefore led to significant decreases in the racial disparity in follow-up rates at our institution in the setting of an existing quality improvement initiative. Further research should focus on the intentional use of telehealth in improving maternal outcomes especially among NH Black.

Patient perceptions, opinions and satisfaction of telehealth with remote blood pressure monitoring postpartum

Background

Our aim was to conduct a post participation survey of respondent experiences with in-home remote patient monitoring via telehealth for blood pressure monitoring of women with postpartum hypertension. We hypothesized that the in-home remote patient monitoring application will be implemented with strong fidelity and have positive patient acceptability.

Methods

This analysis was a planned secondary analysis of a non-randomized controlled trial of telehealth with remote blood pressure patient monitoring for postpartum hypertension compared to standard outpatient monitoring in women with a hypertension-related diagnosis during pregnancy. In collaboration with survey experts, we developed a 41-item web-based survey to assess 1) perception of quality of care received, 2) ease of use/ease to learn the telehealth program, 3) effective orientation of equipment, 4) level of perceived security/privacy utilizing telehealth and 5) problems encountered. The survey included multiple question formats including Likert scale responses, dichotomous Yes/No responses, and free text. We performed a descriptive analysis on all responses and then performed regression analysis on a subset of questions most relevant to the domains of interest. The qualitative data collected through open ended responses was analyzed to determine relevant categories. Intervention participants who completed the study received the survey at the 6-week study endpoint.

Results

Sixty six percent of respondents completed the survey. The majority of women found the technology fit easily into their lifestyle. Privacy concerns were minimal and factors that influenced this included age, BMI, marital status, and readmissions. 95% of women preferred remote care for postpartum follow-up, in which hypertensive type, medication use and ethnicity were found to be significant factors in influencing location of follow-up. Most women were satisfied with the devices, but rates varied by hypertensive type, infant discharge rates and BMI.

Conclusions

Postpartum women perceived the telehealth remote intervention was a safe, easy to use method that represented an acceptable burden of care and an overall satisfying method for postpartum blood pressure monitoring.

Trial registration

ClinicalTrials.gov identification number: NCT03111095 Date of registration: April 12, 2017.

Postpartum blood pressure trends are impacted by race and BMI

OBJECTIVE

Our objective was to evaluate postpartum blood pressure trends, and time to resolution of hypertension among women with hypertensive disorders of pregnancy, specifically focusing on impact of race and BMI on these trends.

METHODS

We performed a secondary analysis of a randomized trial that utilized a text-message based home blood pressure monitoring system. BPs for this study included both inpatient postpartum BPs as well as home BPs obtained from the text-based program. Women were followed from 12 h of delivery to 16 days postpartum. Outcomes were: (1) postpartum BP trend summaries from a linear mixed-effects regression model and (2) time to resolution of hypertension (defined as ≥ 48 h of BPs < 140/90) depicted using Kaplan Meier survival curves with hazard ratio estimates of association using Cox models.

RESULTS

Eighty-four women were included, of which 63% were black. Non-black women with a BMI < 35 kg/m² had steady decreases in systolic BP whereas other groups peaked around 6.5 days postpartum. BPs for women in the BMI < 35 group, regardless of race, remained in the normotensive range. Conversely, women with a BMI ≥ 35 had a systolic BP peak into the hypertensive range prior to declining. Diastolic BP peaked at an average of 8.5 days postpartum. Time to resolution of BPs differed by race and BMI groups (p = 0.012). Non-black women with a BMI < 35 had the shortest time to resolution and 81% of these women had resolution of hypertension. Only 49% of black women with a BMI < 35 had resolution of hypertension and approximately 40% of both black and non-black women with BMI ≥ 35 had resolution of hypertension.

CONCLUSION

We identified race and BMI to be determinants of postpartum BP trends and hypertension resolution. Further study is needed to determine if race and BMI targeted postpartum hypertension interventions may lead to faster blood pressure recovery and lower maternal morbidity postpartum.

Postpartum hypertensive disorders in the Emergency Department - A retrospective review of local practice in Calgary, Alberta

Hypertensive disorders of pregnancy (HDP) commonly occur postpartum and are associated with preventable maternal morbidity and mortality. HDP is the most common reason for presentation to the Emergency Department (ED) after delivery. However, given the broad range of non-specific symptoms, recognition and management of postpartum HDP may be delayed leading to serious adverse clinical outcomes.

OBJECTIVES

To describe: (1) the clinical presentation; (2) ED physician's diagnosis; and (3) current ED management of women with HDP in Calgary ED's.

METHODS

A retrospective review of postpartum women (within 42 days of delivery) attending three Calgary EDs between 2011 and 2012 was performed. Administrative data was used to randomly select 119 women; 44 with diagnostic codes for any HDP (labeled "HDP") and 75 with diagnostic codes for related diagnoses (e.g., abdominal pain, headache) (labeled "non-HDP"). Charts were reviewed for: maternal demographics; obstetrical history; and ED clinical findings, investigations and management.

RESULTS

Maternal characteristics were similar between groups. There was considerable overlap in clinical presentation between groups, with no significant difference for any presenting symptom. Only 52.3% (CI 40.0-64.3%) of women in the "HDP" group had HDP investigations (bloodwork and urinalysis) vs. 30.4% (CI 18.7-58.5%) of "non-HDP" (p = 0.072). HDP was diagnosed by the ED team in 42.9% (CI 31.1-55.5%) of the HDP group of whom only 40.3% (CI 28.7-53.1) received antihypertensive therapy.

CONCLUSIONS

Postpartum HDP is commonly under-recognized and under-treated in the ED, highlighting opportunities for interventions to improve the recognition and management of postpartum HDP.

Oral labetalol versus oral nifedipine for the management of postpartum hypertension a randomized control trial

OBJECTIVE

To compare the efficacy of oral Labetalol versus oral Nifedipine for the treatment of postpartum hypertension.

METHODS

A prospective randomized controlled trial with parallel assignment was conducted in the department of Obstetrics and Gynecology, Dow University of Health Sciences Karachi, Pakistan, 124 patients with post partum hypertension were selected and randomized into two groups with 62 patients receiving Labetalol and 62 receiving long acting nifedipine. Initial blood pressures were recorded, and the respective drug was administered. Dose adjustments were performed in the initial 24 hours. The outcome was measured in the form of drug efficacy by lowering of systolic blood pressure less than 140mm of Hg and diastolic less than 90mm of Hg up to 48 hours after starting treatment. Data was entered and analyzed through SPSS version 20.

RESULTS

Our study randomized 62 women to oral labetalol and 62 women to oral long acting nifedipine. The time required to achieve blood pressure control was 35.6±2.8 hours in labetalol group and 30.4±1.9 hours in nifedipine group (p=0.04).length of hospital stay, need of additional antihypertensive medications were same in both groups. Minor side effects were observed more in nifedipine group.

CONCLUSION

We conclude that both oral labetalol and oral long acting nifedipine are effective and well tolerated interventions for the management of post-partum hypertension. However we found Nifidipine more effective in the management of postpartum hypertension.

Present status of clinical care for postpartum patients with hypertensive disorders of pregnancy in Japan: findings from a nationwide questionnaire survey

OBJECTIVE

To assess the present status of clinical care for postpartum patients with hypertensive disorders of pregnancy (HDP) in Japan.

METHODS

We conducted a nationwide questionnaire survey of obstetricians, internists and hypertension specialists and analyzed 686 valid responses.

RESULTS

Though HDP is widely known as a risk factor for subsequent hypertension and cardiovascular disease, over one-third of obstetricians terminated their postpartum follow-up of HDP patients without referring them to other departments.

CONCLUSION

It is important to establish an effective referral system, whereby patients with HDP can be smoothly transferred to primary care or a specialist physician after childbirth for long-term monitoring and management of blood pressure.