Abstract
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.
Highlights
Recent evidence suggests that maternal morbidity and mortality are increasing in the United States, most of which occur in the 6 weeks after delivery, referred to as the “fourth trimester.”1 The cause of this increase is likely multifactorial, associated with advancing maternal age and medical comorbidities as well as the concomitant limitations of the health care system
At present in the United States, women are typically discharged from the hospital on postpartum days 2 to 4 and the American College of Obstetricians and Gynecologists (ACOG) recommends a single blood pressure check between 3 and 10 days post partum for women with a hypertensive disorder of pregnancy
Women with persistent hypertension or the need for titration of antihypertensive medications are typically seen more frequently in the postpartum period for medication management; as there are no clear guidelines on optimal blood pressure management in this period, this varies by clinician and institution
Summary
Recent evidence suggests that maternal morbidity and mortality are increasing in the United States, most of which occur in the 6 weeks after delivery, referred to as the “fourth trimester.” The cause of this increase is likely multifactorial, associated with advancing maternal age and medical comorbidities as well as the concomitant limitations of the health care system. Black women are at increased risk of hypertensive disorders of pregnancy, and hypertension and cardiovascular diseases are more frequently associated with morbidity and mortality among Black women compared with White women.1,3 These differences are notable in the postpartum period. Women are typically seen at 4 to 6 weeks post partum for a comprehensive postpartum visit and referred to their primary care physician if there are additional needs for antihypertensive medication management.. Women are typically seen at 4 to 6 weeks post partum for a comprehensive postpartum visit and referred to their primary care physician if there are additional needs for antihypertensive medication management.6 This strategy is limited by poor adherence to follow-up, with prior studies showing visit attendance rates of 45% to 60% in this period. At present in the United States, women are typically discharged from the hospital on postpartum days 2 to 4 and the American College of Obstetricians and Gynecologists (ACOG) recommends a single blood pressure check between 3 and 10 days post partum for women with a hypertensive disorder of pregnancy. Women with persistent hypertension or the need for titration of antihypertensive medications are typically seen more frequently in the postpartum period for medication management; as there are no clear guidelines on optimal blood pressure management in this period, this varies by clinician and institution. Subsequently, women are typically seen at 4 to 6 weeks post partum for a comprehensive postpartum visit and referred to their primary care physician if there are additional needs for antihypertensive medication management. This strategy is limited by poor adherence to follow-up, with prior studies showing visit attendance rates of 45% to 60% in this period.
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