Postpartum health-care utilization and blood pressure control by antihypertensive agent in hypertensive disorders of pregnancy.

Introduction: Hypertensive disorders of pregnancy (HDP) contribute to postpartum complications and readmissions. Remote blood pressure monitoring (RBPM) offers an effective alternative for tracking postpartum health. However, evidence on its benefits compared to OB-GYN clinic visits is limited. This study aims to determine whether remote postpartum blood pressure monitoring improves clinical outcomes over traditional follow-ups for individuals with a history of hypertensive disorders during pregnancy. Methods: A literature search was conducted following PRISMA guidelines across PubMed, Google Scholar, and Embase for studies on postpartum outcomes using RBPM via text, telehealth, home-based platforms, or clinic care. Primary outcomes were blood pressure control, follow-up adherence, and hospital readmissions. Secondary outcomes included blood pressure reporting, emergency room visits, and patient satisfaction. Random-effects models analyzed pooled proportions with 95% confidence intervals (CI). Statistical significance was set at p<0.05. Results: Thirteen studies included over 18,833 postpartum individuals with HDP. Compared with clinic-based care, remote monitoring significantly reduced readmissions (OR: 0.45; 95% CI: 0.24-0.87; p=0.017), improved blood pressure control (<140/90mmHg) (OR: 0.48; 95% CI: 0.27-0.87; p=0.016), and increased blood pressure reporting (OR: 1.76; 95% CI: 1.19-2.62; p=0.005) (Fig 1). However, remote monitoring was associated with increased emergency room visits (OR: 18.72; 95% CI: 1.46-240.32; p=0.025), possibly indicating earlier triage. Single-arm analyses (Fig 2) of RBPM cohorts reported high follow-up adherence (OR: 14.63; 95% CI: 0.88-242.19; p=0.061), low readmission rates (OR: 0.13; 95% CI: 0.07-0.22; p<0.001), and low emergency visit rates (OR: 0.08; 95% CI: 0.05-0.11; p<0.001). Medication titration was moderate (OR: 0.52; 95% CI: 0.39-0.66; p<0.001), and patient satisfaction was high (OR: 2.95; 95% CI: 0.61-14.39; p=0.179). Moderate to High heterogeneity was observed among all the analyses. Conclusion: RBPM improves postpartum management by enhancing follow-up adherence, control, and reporting, while lowering readmission rates. Increased emergency visits indicate timely detection rather than negative outcomes. Further research is needed to assess the impact of socioeconomic factors, insurance coverage, and access to care on the implementation and effectiveness of interventions across diverse populations.

Effect of postpartum oral furosemide use on postpartum readmissions and blood pressure trends.

911 Readmission for hypertension among women in a postpartum remote blood pressure monitoring program

Remote blood pressure monitoring refers to an organized framework that either allows clinicians to review home-based blood pressure readings and institute management, or provide participants with clear instructions for contacting care teams when blood pressure readings are out of prespecified targets. With widespread uptake of telemonitoring and mobile health in recent years, such models of care have been increasingly described in the literature. This study aimed to review remote blood pressure monitoring in pregnant and postpartum women who are at high-risk for or have an established diagnosis of hypertensive disorders of pregnancy, and its effect on maternal and fetal outcomes, healthcare utilization and psychosocial outcomes. PubMed, Medline, Embase, Cochrane Library, Web of Science and CINAHL databases were searched electronically in June 2024 to their inception. Included studies compared remote blood pressure monitoring with standard care. Remote blood pressure monitoring was pre-defined as any framework for measuring blood pressure remotely in pregnancy, with organized review by clinicians. Published full-text and study abstracts describing randomized controlled trials and observational studies were included. The study population was pregnant women at high-risk for developing pre-eclampsia or postpartum (<6 weeks) women with an established diagnosis of a hypertensive disorder of pregnancy. Remote blood pressure monitoring undertaken in the antenatal and postnatal periods were analyzed separately. This systematic review was conducted according to the Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement. Screening of records and data extraction were independently performed. Data were extracted and analyzed using Review Manager software (version 5.4; Cochrane Collaboration, Copenhagen, Denmark). Risk of bias and quality assessment was performed independently using the Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I) assessment tool and the Cochrane Risk of Bias 2 (RoB2) tool. A total of 18 studies with 28 094 patients were included. Antenatal remote blood pressure monitoring reduces antenatal outpatient visits, antenatal hospital admissions for any cause, and antenatal hospital admissions specifically for hypertension. Importantly, there was no increase in adverse maternal and fetal outcomes, including the likelihood of cesarean section deliveries or induction of labor due to hypertension, composite maternal outcome, growth restriction, neonatal intensive care unit admissions, gestational age at delivery and the composite fetal outcome. Psychosocial outcomes were also not significantly different between the remote blood pressure monitoring and usual care groups. Postpartum remote blood pressure monitoring in women with an established hypertensive disorder of pregnancy led to greater compliance with blood pressure follow-up within 10 days, with no increase in unscheduled hypertension-related presentations, postpartum readmissions or outpatient antihypertensive prescription. Utilizing a model of remote blood pressure monitoring which incorporates organized review and management by clinicians, may reduce antenatal outpatient visits and admissions, without increasing adverse fetal and maternal outcomes, in pregnant women who require frequent monitoring of their blood pressure. In postpartum women with a hypertensive disorder of pregnancy, remote blood pressure monitoring can improve guideline recommended follow-up within 10 days. However, the meta-analysis was hampered by study heterogeneity and a paucity of high-quality evidence. Further randomized controlled trials are needed to confirm the findings of this review and provide recommendations.

Implementation of a text-based postpartum blood pressure monitoring program at 3 different academic sites

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

Hypertensive disorders of pregnancy affect approximately 15% of pregnancies in the United States and are a leading cause of postpartum readmissions. Morbidity due to hypertension may be higher in the first several weeks postpartum. The ability to monitor blood pressure and intervene in the postpartum period is critical to reducing morbidity and mortality. At WellSpan Health, hypertensive disorders were increasing and a leading cause of severe maternal morbidity and readmission. A remote blood pressure monitoring app called BabyScripts™ myBloodPressure was implemented in September 2020. Prior to discharge postpartum, all patients with a diagnosis of a hypertensive disorder of pregnancy were given an automatic blood pressure cuff and instructions on how to monitor and track their blood pressure daily in the app. A total of 1,260 patients were enrolled in the BabyScripts™ myBloodPressure module between September 2020 and July 2022 across five maternity hospitals. Of those enrolled 74% ( n = 938) entered seven or more blood pressures, and of those who entered at least one blood pressure 9% ( n = 107) entered at least one critical range blood pressure ( ≥ 150 mmHg systolic and or ≥ 100 mmHg diastolic). Most women enrolled in the app were highly engaged and entered seven or more readings. Patients with critical blood pressures were identified; thus, the program has the potential to identify those at risk of severe complications. Barriers should be removed, and remote patient monitoring considered as a solution to improve postpartum assessment in patients with hypertensive disorders of pregnancy.

Remote blood pressure monitoring (RBPM) is a promising method for surveilling hypertensive disorders of pregnancy (HDP). This refers to an organised framework in which clinicians can review and manage patient-obtained blood pressure recordings. Successful integration of RBPM into routine antenatal care necessitates understanding patient and clinician perspectives of its use. This study sought to evaluate the perceptions of high-risk pregnant women and clinicians regarding RBPM's use in HDP surveillance. A web-based questionnaire was distributed to pregnant women in South Western Sydney and clinicians across Australia and New Zealand. Quantitative Likert scales and qualitative open-ended questions were used to ascertain perceptions about RBPM for the surveillance of HDP. Seventy-six women responded to the patient survey, with a response rate of 74.5%. A total of 65 clinicians responded to the healthcare professional survey. Almost all women (97.4%) supported RBPM's potential to aid healthcare decisions, with 96.1% willing to incorporate RBPM into antenatal care. Linear regression revealed implementation of RBPM was particularly supported by women who had less time off from paid employment during their pregnancy (p < 0.001). Conversely, women from non-English-speaking backgrounds and lower-income groups perceived RBPM as more challenging to use (p = 0.011 and p = 0.017, respectively). Most clinicians were concerned about the security of data transfer and storage interfaces. Poor accuracy or reliability of the technology emerged as a common barrier amongst both women and clinicians. Free-text responses revealed novel themes including accountability of care and medicolegal ramifications. Though socioeconomic status, ethnicity and language influenced perceptions towards RBPM; overall, Australian pregnant women and clinicians are broadly receptive to its use in antenatal care. Successful implementation of RPBM requires careful evaluation of design and workflow to accommodate for patient diversity, ease of use, compliance, privacy and clinical utility to optimise the user experience.

To evaluate differences in health care utilization and guideline adherence for postpartum individuals with hypertensive disorders of pregnancy (HDP) who are engaged in a remote monitoring program, compared with usual care. This was a retrospective cohort study of postpartum individuals with HDP who delivered between March 2019 and June 2023 at a single institution. The primary exposure was enrollment in a remote hypertension management program that relies on patient home blood pressure (BP) measurement and centralized nursing team management. Patients enrolled in the program were compared with those receiving usual care. Outcomes included postpartum readmission, office visit within 6 weeks postpartum, BP measurement within 10 days, and initiation of antihypertensive medication. We performed multivariable logistic and conditional regression in a propensity score matched cohort. Propensity scores, generated by modeling likelihood of program participation, were assessed for even distribution by group, ensuring standardized bias of less than 10% after matching. Overall, 12,038 eligible individuals (6,556 participants, 5,482 in the control group) were included. Program participants were more likely to be White, commercially insured, be diagnosed with preeclampsia, and have higher prenatal and inpatient postpartum BPs. Differences in baseline factors were well-balanced after implementation of propensity score. Program enrollment was associated with lower 6-week postpartum readmission rates, demonstrating 1 fewer readmission for every 100 individuals in the program (propensity score-matched adjusted risk difference [aRD] -1.5, 95% CI, -2.6 to -0.46; adjusted risk ratio [aRR] 0.78, 95% CI, 0.65-0.93). For every 100 individuals enrolled in the program, 85 more had a BP recorded within 10 days (propensity score-matched aRD 85.4, 95% CI, 84.3-86.6), and six more had a 6-week postpartum office visit (propensity score-matched aRD 5.7, 95% CI, 3.9-7.6). Program enrollment was also associated with increased initiation of an antihypertensive medication postpartum (propensity score-matched aRR 4.44, 95% CI, 3.88-5.07). Participation in a postpartum remote BP monitoring program was associated with fewer postpartum hospital readmissions, higher attendance at postpartum visits, improved guideline adherence, and higher rates of antihypertensive use.

Maternal morbidity and mortality are increasing in the United States, most of which occur post partum, with significant racial disparities, particularly associated with hypertensive disorders of pregnancy. Blood pressure trajectory after a hypertensive disorder of pregnancy has not been previously described. To describe the blood pressure trajectory in the first 6 weeks post partum after a hypertensive disorder of pregnancy and to evaluate whether blood pressure trajectories differ by self-reported race. This prospective cohort study included deliveries between January 1, 2018, and December 31, 2019. Women with a clinical diagnosis of a hypertensive disorder of pregnancy were enrolled in a postpartum remote blood pressure monitoring program at the time of delivery and were followed up for 6 weeks. Statistical analysis was performed from April 6 to 17, 2020. Mixed-effects regression models were used to display blood pressure trajectories in the first 6 weeks post partum. A total of 1077 women were included (mean [SD] age, 30.2 [5.6] years; 804 of 1017 White [79.1%] and 213 of 1017 Black [20.9%]). Systolic and diastolic blood pressures were found to decrease rapidly in the first 3 weeks post partum, with subsequent stabilization (at 6 days post partum: mean [SD] peak systolic blood pressure, 146 [13] mm Hg; mean [SD] peak diastolic blood pressure, 95 [10] mm Hg; and at 3 weeks post partum: mean [SD] peak systolic blood pressure, 130 [12] mm Hg; mean [SD] peak diastolic blood pressure, 85 [9] mm Hg). A significant difference was seen in blood pressure trajectory by race, with both systolic and diastolic blood pressure decreasing more slowly among Black women compared with White women (mean [SD] peak systolic blood pressure at 1 week post partum: White women, 143 [14] mm Hg vs Black women, 146 [13] mm Hg; P = .01; mean [SD] peak diastolic blood pressure at 1 week post partum: White women, 92 [9] mm Hg vs Black women, 94 [9] mm Hg; P = .02; and mean [SD] peak systolic blood pressure at 3 weeks post partum: White women, 129 [11] mm Hg vs Black women, 136 [15] mm Hg; P < .001; mean [SD] peak diastolic blood pressure at 3 weeks post partum: White women, 84 [8] mm Hg vs Black women, 91 [13] mm Hg; P < .001). At the conclusion of the program, 126 of 185 Black women (68.1%) compared with 393 of 764 White women (51.4%) met the criteria for stage 1 or stage 2 hypertension (P < .001). This study found that, in the postpartum period, blood pressure decreased rapidly in the first 3 weeks and subsequently stabilized. The study also found that, compared with White women, Black women had a less rapid decrease in blood pressure, resulting in higher blood pressure by the end of a 6-week program. Given the number of women with persistent hypertension at the conclusion of the program, these findings also appear to support the importance of ongoing postpartum care beyond the first 6 weeks after delivery.

Importance: It is anticipated that many women do not get enough sleep after delivery. However, it is unclear how poor sleep affects postpartum blood pressure. Objective: To investigate the relationship between postpartum blood pressure and sleep habits, we examined women who developed hypertensive disorders of pregnancy by using automated blood pressure monitors and accelerometers. Setting: The blood pressure, pulse rate, and sleep were monitored at home. Total sleep time, sleep efficiency, sleep fragmentation coefficient, and wake after sleep onset were measured. Participants completed a behavior chart including breastfeeding frequency. The 24-hour, awake time and sleep time mean blood pressures were calculated for each participant as well as the change in blood pressure between postpartum days 7 and 14. Participants: We recruited 11 women who delivered singletons and developed hypertensive disorders of pregnancy at the National Center for Child Health and Development from April to September 2021. Intervention or Exposure: None Main Outcomes: The relationship between the change in blood pressure and sleep measurements and frequency of breastfeeding were analyzed. Results: Seven participants were included in the final analysis. The mean total sleep time was 5.3 hours, and the mean breastfeeding frequency was 6.1 times per day. Mean systolic and diastolic blood pressure and pulse rate during sleep periods tended to be lower than those during awake periods (-8.5±4.5 mmHg, -8.8±2.7 mmHg, -8.7±2.7 bpm, respectively). Lower sleep time was significantly correlated with smaller 24h-systolic and diastolic blood pressure drop (correlation coefficient r=-0.823, p=0.023 and r=-0.812, p=0.026, respectively. No association was found between other sleep measurements and the change in 24h-blood pressure. The blood pressure and pulse rate values in six of the seven participants during the early sleep phase (≤30 min) were similar to those in later sleep phases (&gt;30 min), showing that beneficial effects of sleep on blood pressure were apparent throughout the sleep phases. Conclusions and Relevance: Our results suggest that longer total sleep time, even if sleep is fragmented, is associated with a greater decrease in postpartum blood pressure among women who developed hypertensive disorders of pregnancy.

After a hypertensive disorder of pregnancy, hypertension can worsen in the postpartum period following hospital discharge. Risk factors for ongoing hypertension and associated outcomes have not been well characterized. To identify risk factors and characterize outcomes for individuals with ongoing hypertension and severe hypertension following hospital discharge post partum through a hospital system's remote blood pressure (BP) management program. This cohort study involved a population-based sample of individuals with a new-onset hypertensive disorder of pregnancy (preeclampsia or gestational hypertension) and no prepregnancy hypertension who delivered between September 2019 and June 2021. Participants were enrolled in a remote BP monitoring and management program at a postpartum unit at a referral hospital. Data analysis was performed from August 2021 to January 2023. Inpatient postpartum BP categories. The primary outcomes were readmission and emergency department visits within the first 6 weeks post partum. Logistic regression was used to model adjusted odds ratios (aORs) and 95% CIs. Of 2705 individuals in the cohort (mean [SD] age, 29.8 [5.7] years), 2214 (81.8%) had persistent hypertension post partum after hospital discharge, 382 (14.1%) developed severe hypertension after discharge, and 610 (22.6%) had antihypertensive medication initiated after discharge. Individuals with severe hypertension had increased odds of postpartum emergency department visits (aOR, 1.85; 95% CI, 1.17-2.92) and hospital readmissions (aOR, 6.75; 95% CI, 3.43-13.29) compared with individuals with BP normalization. When inpatient postpartum BP categories were compared with outpatient home BP trajectories to inform optimal thresholds for inpatient antihypertensive medication initiation, there was significant overlap between postdischarge BP trajectories among those with inpatient systolic BP greater than or equal to 140 to 149 mm Hg and/or diastolic BP greater than or equal to 90 to 99 mm Hg and those with systolic BP greater than or equal to 150 mm Hg and/or diastolic BP greater than or equal to 100 mm Hg. This cohort study found that more than 80% of individuals with hypertensive disorders of pregnancy had ongoing hypertension after hospital discharge, with approximately 14% developing severe hypertension. These data support the critical role of remote BP monitoring programs and highlight the need for improved tools for risk stratification and consideration of liberalization of thresholds for medication initiation post partum.

Aim: to evaluate the efficacy of antihypertensive therapy (AHT) using remote blood pressure (BP) and heart rate (HR) monitoring at home. Materials and Methods: the study included 30 adult patients (&amp;ge;18 years) with uncontrolled essential hypertension despite receiving 1–3 antihypertensive medications. The cohort comprised 11 males and 19 females, with a mean age of 58.65±11.03 years. All participants underwent a comprehensive physical examination and medical history assessment to determine cardiovascular risk. Office blood pressure measurements were obtained, and patients completed a quality of life questionnaire using a visual analog scale (VAS) and an adherence assessment using the Morisky-Green scale. Psychological status was evaluated with the Hospital Anxiety and Depression Scale (HADS). At baseline (visit 0), patients were screened and provided with automated BP monitors equipped with GSM modules for remote BP and HR monitoring. At visit 1, all patients were initiated on a fixed-dose combination therapy of azilsartan medoxomil/chlortalidone (Az+CLT) 40 mg/12.5 mg. Visit 2 was conducted either in person or remotely four weeks following initiation of Az+CLT, at which point therapy was adjusted if necessary. Visit 3 was performed eight weeks after therapy initiation. Results: at visit 2, two patients required therapeutic adjustments – increasing the dose to a maximum of 40+25 mg (Edarbi® Clo) according to the instructions. By visit 3, there was a statistically significant reduction in office systolic BP (SBP), diastolic BP (DBP), and HR compared to baseline. Notably, during Az+CLT administration and normalization of BP, reductions in anxiety and depression scores (HADS) and improvements in quality of life were observed. Remote monitoring data confirmed a decrease in the mean weekly SBP and DBP at both four and eight weeks. HR did not change significantly from baseline during therapy. Based on office measurements, target BP (&lt;130/80 mmHg) was achieved in all patients. When assessed by remote monitoring, 81.8% of patients achieved a mean weekly BP of &lt;135/85 mmHg, while 63.6% reached &lt;130/80 mmHg. The proportion of patients maintaining the BP target (&lt;135/85 mmHg) at two months was 43.3% (n=13). Conclusion: remote BP and HR monitoring is a reliable and effective tool for therapy management. The fixed-dose combination of Az+CLT demonstrates efficacy both in office-based BP measurements and in long-term ambulatory BP monitoring employing remote technologies. Keywords: remote blood pressure and heart rate monitoring at home, azilsartan medoxomil/chlortalidone, hypertension, blood pressure monitoring, office blood pressure. For citation: Ageev F.T., Smirnova M.D., Fofanova T.V. Evaluation of the antihypertensive therapy efficacy with remote blood pressure monitoring using the example of a fixed combination of azilsartan and chlortalidone. RMJ. 2025;6:10–16. DOI: 10.32364/2225-2282-2025-6-3

Masked pregnancy-associated hypertension as a predictor of adverse outcomes

90: A randomized controlled trial of ibuprofen on postpartum blood pressure in hypertensive disorders of pregnancy