Management Of Hypertensive Disorders In Pregnancy Research Articles

The Role of Regulatory T Cells and Their Therapeutic Potential in Hypertensive Disease of Pregnancy: A Literature Review.

Hypertensive disorders of pregnancy (HDP), including preeclampsia (PE) and gestational hypertension (GH), are major causes of maternal and foetal morbidity and mortality. This review elucidates the role of regulatory T cells (Tregs) in the immunological aspects of HDP and explores their therapeutic potential. Tregs, which play a critical role in maintaining immune homeostasis, are crucial in pregnancy to prevent immune-mediated rejection of the foetus. The review highlights that Tregs contribute to immunological adaptation in normal pregnancy, ensuring foetal acceptance. In contrast, HDP is associated with Treg dysfunction, which is marked by decreased numbers and impaired regulatory capacity, leading to inadequate immune tolerance and abnormal placental development. This dysfunction is particularly evident in PE, in which Tregs fail to adequately modulate the maternal immune response against foetal antigens, contributing to the pathophysiology of the disorder. Therapeutic interventions aiming to modulate Treg activity represent a promising avenue for HDP management. Studies in animal models and limited clinical trials suggest that enhancing Treg functionality could mitigate HDP symptoms and improve pregnancy outcomes. However, given the multifactorial nature of HDP and the intricate regulatory mechanisms of Tregs, the review explores the complexities of translating in vitro and animal model findings into effective clinical therapies. In conclusion, while the precise role of Tregs in HDP is still being unravelled, their central role in immune regulation during pregnancy is indisputable. Further research is needed to fully understand the mechanisms by which Tregs contribute to HDP and to develop targeted therapies that can safely and effectively harness their regulatory potential for treating hypertensive diseases of pregnancy.

Management of hypertensive disorders in pregnancy: a Position Statement of the European Society of Hypertension Working Group 'Hypertension in Women'.

Hypertensive disorders in pregnancy (HDP), remain the leading cause of adverse maternal, fetal, and neonatal outcomes. Epidemiological factors, comorbidities, assisted reproduction techniques, placental disorders, and genetic predisposition determine the burden of the disease. The pathophysiological substrate and the clinical presentation of HDP are multifarious. The latter and the lack of well designed clinical trials in the field explain the absence of consensus on disease management among relevant international societies. Thus, the usual clinical management of HDP is largely empirical. The current position statement of the Working Group 'Hypertension in Women' of the European Society of Hypertension (ESH) aims to employ the current evidence for the management of HDP, discuss the recommendations made in the 2023 ESH guidelines for the management of hypertension, and shed light on controversial issues in the field to stimulate future research.

Risk factors and prediction model for new-onset hypertensive disorders of pregnancy: a retrospective cohort study.

Hypertensive disorders of pregnancy (HDP) is a significant cause of maternal and neonatal mortality. This study aims to identify risk factors for new-onset HDP and to develop a prediction model for assessing the risk of new-onset hypertension during pregnancy. We included 446 pregnant women without baseline hypertension from Liyang People's Hospital at the first inspection, and they were followed up until delivery. We collected maternal clinical parameters and biomarkers between 16th and 20th weeks of gestation. Logistic regression was used to determine the effect of the risk factors on HDP. For model development, a backward selection algorithm was applied to choose pertinent biomarkers, and predictive models were created based on multiple machine learning methods (generalised linear model, multivariate adaptive regression splines, random forest, and k-nearest neighbours). Model performance was evaluated using the area under the curve. Out of the 446 participants, 153 developed new-onset HDP. The HDP group exhibited significantly higher baseline body mass index (BMI), weight change, baseline systolic/diastolic blood pressure, and platelet counts than the control group. The increase in baseline BMI, weight change, and baseline systolic and diastolic blood pressure significantly elevated the risk of HDP, with odds ratios and 95% confidence intervals of 1.10 (1.03-1.17), 1.10 (1.05-1.16), 1.04 (1.01-1.08), and 1.10 (1.05-1.14) respectively. Restricted cubic spline showed a linear dose-dependent association of baseline BMI and weight change with the risk of HDP. The random forest-based prediction model showed robust performance with the area under the curve of 0.85 in the training set. This study establishes a prediction model to evaluate the risk of new-onset HDP, which might facilitate the early diagnosis and management of HDP.

Health-related needs of survivors of hypertensive disorders of pregnancy: implications for health communication interventions

ABSTRACT Background: Hypertensive disorders of pregnancy (HDP) are key contributors to maternal morbidity, mortality, and future risk of cardiovascular disease. This exploratory study aimed to unearth the health-related needs of women with a reported history of HDP by inquiring about preferences for care. Method: Deductive, qualitative analysis was conducted of HDP survivors’ retrospective ‘wishes’ about the care received. Results: In analyzing 244 open-ended, online survey responses, we identified a taxonomy of health-related needs arising across the trajectory of HDP: clinical information, needs requiring clinical knowledge, such as information about the etiology or prognosis of HDP; medical, needs associated with HDP intervention and management; logistical, needs regarding practical information, such as how to contact a provider or obtain the correct medical device; emotional, needs involving a desire for support or validation; and communication, needs for improved explanations and recognition of HDP. Conclusions: A taxonomy of diverse health-related needs may assist clinicians in approaching HDP patients more holistically. Additionally, opportunities exist for health communication research to inform standard approaches to HDP-related communication flowing from provider to patient.

Uterine Artery Doppler Indices as Predictor of Adverse Fetal Outcome in Hypertensive Disorders of Pregnancy: An Observational Study.

Background Hypertensive disorders of pregnancy (HDP) pose significant risks to maternal and fetal health. The utility of Doppler indices in predicting adverse fetal outcomes in HDP patients remains an area of active research. This observational study aimed to assess the correlation between abnormal uterine artery Doppler indices and adverse fetal outcomes in HDP patients. Methods Over a two-year period, we enrolled 138 pregnant women with HDP beyond 28 weeks of gestation and singleton pregnancies. Detailed clinical assessments, laboratory investigations, and Doppler studies of the uterine artery were conducted. The Doppler indices that were assessed included the systolic/diastolic (S/D) ratio, resistance index (RI), and pulsatility index (PI). Adverse fetal outcomes were classified based on appearance, pulse, grimace, activity, and respiration (APGAR) scores, birth weight, NICU admissions, and perinatal deaths. Statistical analyses were performed to evaluate the predictive value of Doppler indices. Results Abnormal uterine artery Doppler indices, specifically an elevated S/D ratio and the presence of a diastolic notchshowed a positive correlation with adverse fetal outcomes. However, Doppler indices such as PI and RI did not demonstrate a significant correlation with adverse fetal outcomes in HDP patients. These findings suggest that the S/D ratio and the presence of a diastolic notch in uterine artery Doppler studies hold potential as predictive markers for adverse fetal outcomes in HDP patients. Conclusion Uterine artery Doppler indices, specifically the S/D ratio and the presence of a diastolic notch, appear to be valuable predictors for adverse fetal outcomes in patients with hypertensive disorders of pregnancy. These findings underscore the importance of regular monitoring of uterine artery Doppler flow in the management of HDP to identify pregnancies at higher risk for adverse fetal outcomes.

Platelet indices and angiogenesis markers in hypertensive disorders of pregnancy.

Activated platelets exert a key role in the pathogenesis of preeclampsia (PE). There is evidence of distinctive patterns of platelet indices in PE in comparison to healthy pregnancies, therefore these indices can be potential tools for PE detection, risk stratification, and management. Considering the vascular aspects of its pathophysiology, PE is characterized by the increased levels of soluble FMS-like tyrosine kinase-1 (sFlt-1) an antiangiogenic factor, and reduced placental growth factor (PlGF), a proangiogenic factor. This study aimed to assess the platelet indices in hypertensive disorders of pregnancy (HDP) and its correlation with angiogenesis-related biomarkers. The groups for the study were: control (n = 114); gestational hypertension; (n = 112), and PE (n = 42). The platelet indices included were platelet counts (PLT-I and PLT-F), mean platelet volume (MPV), platelet distribution width (PDW), plateletcrit (PCT), platelet large cell ratio (P-LCR), and immature platelet fraction (IPF# and IPF%). Serum levels of sFlt-1 and PlGF were assessed. PLT-I, PLT-F, and PCT% were lower in PE, while MPV, PDW, P-LCR, IPF%, and IPF# were increased. The parameter MPV presented the best performance for the discrimination of PE. There was a moderate positive correlation between sFlt-1 levels and MPV, PDW, and P-LCR. Platelet indices can be potentially applied as additional tools for the diagnosis and management of HDP. Activated platelets may act as an extra source of sFlt-1 in PE.

Facilitators and barriers to optimal home blood pressure management in patients with hypertensive disorders of pregnancy in a tertiary care facility in Abuja, Nigeria: a qualitative research study

BackgroundNigeria has one of the highest burdens of maternal deaths globally, and hypertensive disorders of pregnancy (HDP) are the leading cause of maternal morbidity and mortality in the country. There is a significant implementation gap in utilizing evidence-based practices for the management of HDP in Nigeria. This study evaluated facilitators and barriers to implementing a home blood pressure monitoring program to improve management of HDP.MethodsFrom August 2022 to September 2022, we conducted 15 semi-structured, key informant interviews and 4 focus group discussions among patients, health care workers, and administrators at University of Abuja Teaching Hospital (UATH), a tertiary care centre in Nigeria. The study used the Consolidated Framework for Implementation Research to assess five domains: individual characteristics, inner and outer settings, intervention characteristics, and process of implementation. Audio files were transcribed, and data were analysed using a combination of inductive and deductive approaches. We also conducted 32 brief surveys on the participants to assess acceptability, appropriateness, and feasibility of a blood pressure monitoring program.ResultsThe study sample consisted of healthcare workers (n=22) including specialists in cardiology, obstetrics and gynaecology, maternal-foetal medicine, nurses/midwives and resident doctors as well as patients (n=10). Mean (SD) age was 39.5 (10.9), and 78% were female. Participants identified facilitators including the perceived simplicity of home blood pressure monitoring program, high burden of HDP, and availability of a multi-disciplinary team of healthcare professionals with expertise in HDP management. Barriers identified were cost, limited knowledge of HDP amongst patients, limited transportation networks, inconsistent management protocols, and inadequate manpower and facilities. Survey results indicated that between 81% and 88% of participants reported that a blood pressure monitoring program would be acceptable, 56%-72% reported that it would be appropriate, and 47%-69% reported that it would be feasible.ConclusionThis study identified facilitators and barriers while highlighting key implementation strategies to leverage and effectively address these respectively to enable successful implementation of a home blood pressure monitoring program. It also demonstrated that a home blood pressure monitoring program was considered acceptable, appropriate and feasible among respondents interviewed at UATH.

Association of ambient PM1 exposure with maternal blood pressure and hypertensive disorders of pregnancy in China

Evidence concerning PM1 exposure, maternal blood pressure (BP), and hypertensive disorders of pregnancy (HDP) is sparse. We evaluated the associations using 105,063 participants from a nationwide cohort. PM1 concentrations were evaluated using generalized additive model. BP was measured according to the American Heart Association recommendations. Generalized linear mixed models were used to assess the PM1-BP/HDP associations. Each 10μg/m3 higher first-trimester PM1 was significantly associated with 1.696mmHg and 1.056mmHg higher first-trimester SBP and DBP, and with 11.4% higher odds for HDP, respectively. The above associations were stronger among older participants (>35 years) or those educated longer than 17 years or those with higher household annual income (> 400,000 CNY). To conclude, first-trimester PM1 were positively associated with BP/HDP, which may be modified by maternal age, education level, and household annual income. Further research is warranted to provide more information for both health management of HDP and environmental policies enactment.

Implementation of a home blood pressure monitoring program for the management of hypertensive disorders of pregnancy, an observational study in British Columbia, Canada.

COVID-19 pandemic has influenced health care delivery. We conducted an observational study to understand how obstetric medicine (ObM) physicians utilized home blood pressure monitoring (HBPM) to manage hypertension in pregnancy. Pregnant participants with risk factors or diagnosis of hypertensive disorders of pregnancy (HDP) were enrolled, May 2020-December 2021, and provided with validated home blood pressure (BP) monitor. ObM physicians completed questionnaires to elicit how home BP readings were interpreted to manage HDP. We enrolled 103 people: 44 antepartum patients (33.5 ± 5 years, gestational age of 24 ± 5 weeks); 59 postpartum patients (35 ± 6 years, enrolled 6 ± 4 days post-partum). ObM physicians used range of home BP readings (70%) for management of HDP. HBPM to manage HDP is acceptable and can be used to manage hypertension during pregnancy. Further studies are needed to assess the generalizability of our findings and the safety of HBPM reliance alone in management of HDP.

Remote Patient Monitoring for Postpartum Hypertensive Disorders of Pregnancy [ID: 1378058

INTRODUCTION: Hypertensive disorders of pregnancy (HDP) account for 2.5–4.6% of readmissions within 6 weeks postpartum (PP); 60% occur in the first 7 days. A standardized approach to HDP management can improve outcomes through optimized PP blood pressure (BP) management. Remote patient monitoring (RPM) has established safety, outcomes, financial benefit, and increased compliance. The primary outcome of this study was to determine the feasibility of a standardized RPM program for PP patients with HDP. METHODS: Participants (n=30) received a phone application and BP monitor that automatically uploaded data to a nurse practitioner (NP)-monitored dashboard. Participants were asked to record a single BP twice daily (6 am–11 am and 6 pm–11 pm) until 10 days PP. Telehealth visits with an NP occurred at 48 hours postdischarge. Feasibility was measured using a one-sided t test of the proportion of participants with satisfaction (via validated Likert-style post-participation surveys) and adherence of 80% or higher (recorded BPs/expected BPs). Secondary outcomes included readmissions, elevated BPs (mild, 140–159/90–109 mm Hg; severe, ≥160/110 mm Hg), and antihypertensive medication up-titration. RESULTS: One hundred percent of participants completed the program. Overall adherence rate was 91%, and overall satisfaction rate was 92%. Of 450 recorded BP measurements, 88 (19.6%) were mild and 2 (0.4%) were severe, with 0 hospital readmissions. Medication up-titration occurred seven times in six participants (20%). We demonstrated feasibility with a proportion of 0.767 participants (P=.0027; CI: 0.577, 0.885). CONCLUSION: A standardized RPM program for PP HDP utilizing early telemedicine visits with an NP successfully demonstrated feasibility in a pilot sample of PP patients. Compliance with PP follow-up recommendations was high. Future work to improve systems innovation for BP optimization in PP patients is needed.

Management of hypertensive disorders of pregnancy in two Australian tertiary care maternity hospitals.

Hypertensive disorders of pregnancy (HDP) are common obstetric medical problems. Compliance with clinical guidelines and evidence from major trials has the potential to translate to significantly improve maternal and perinatal outcomes. The aims of this study were to prospectively review management of HDP in an Australian cohort in the context of the Society of Obstetric Medicine of Australian and New Zealand (SOMANZ) guidelines and current evidence in published literature regarding management controversies. The management of 100 pregnant women with HDP and prescription for antihypertensive medication at two tertiary obstetric centres was prospectively reviewed in 2013. Compliance with SOMANZ guidelines, uptake of findings from the HYPITAT trial and the Control of Hypertension In Pregnancy Study (CHIPS) trial were assessed. Sixty-eight women had chronic hypertension, while 32 had gestational hypertension. Management of HDP was mostly consistent with current SOMANZ guidelines and evidence from CHIPS and HYPITAT. Clinicians were practising according to the current SOMANZ guidelines, indicating vigilance on behalf of the treating team.

Examining changes in clinical management and postpartum readmissions for hypertensive disorders of pregnancy over time.

In response to 2013 guidelines for hypertensive disorders of pregnancy (HDP), our study examined changes in antenatal management and postpartum readmission (PPR) over time. This is a retrospective cohort study of individuals diagnosed antenatally with HDP who delivered at a tertiary care center from 2012 to 2017. The primary outcome was postpartum readmission for HDP in 2012-2013 vs 2014-2017. Secondary outcomes included intravenous magnesium administration and prescription for oral (PO) antihypertensive medication during delivery admission. Multivariable logistic regression models assessed differences in outcomes over time, adjusted for age, race, and payer status, for HDP with and without severe features, defined by ACOG criteria. Of 5,300 eligible individuals, 73.5% had HDP without severe features and 26.5% had severe features. The PPR frequency in this cohort was 1.1% (N=59). There was no difference in PPR for individuals with HDP without severe features (aOR 0.73; 95% CI 0.28-1.88) or with severe features (aOR 1.30; 95% CI 0.50-3.39) by epoch. Magnesium administration for HDP with severe features remained below 80% over time. Magnesium administration for HDP without severe features and discharge prescriptions for PO medications for HDP with severe features were lower after 2013. Neither magnesium administration nor discharge prescriptions were associated with decreased odds of PPR. Although there was no difference in PPR for HDP after 2013, there were changes in antenatal management of HDP, including decreased magnesium administration for individuals with HDP without severe features and PO medication for individuals with severe features.

A global view of hypertensive disorders and diabetes mellitus during pregnancy

Two important maternal cardiometabolic disorders (CMDs), hypertensive disorders in pregnancy (HDP) (including pre-eclampsia) and gestational diabetes mellitus (GDM), result in a large disease burden for pregnant individuals worldwide. A global consensus has not been reached about the diagnostic criteria for HDP and GDM, making it challenging to assess differences in their disease burden between countries and areas. However, both diseases show an unevenly distributed disease burden for regions with a low income or middle income, or low-income and middle-income countries (LMICs), or regions with lower sociodemographic and human development indexes. In addition to many common clinical, demographic and behavioural risk factors, the development and clinical consequences of maternal CMDs are substantially influenced by the social determinants of health, such as systemic marginalization. Although progress has been occurring in the early screening and management of HDP and GDM, the accuracy and long-term effects of such screening and management programmes are still under investigation. In addition to pharmacological therapies and lifestyle modifications at the individual level, a multilevel approach in conjunction with multisector partnership should be adopted to tackle the public health issues and health inequity resulting from maternal CMDs. The current COVID-19 pandemic has disrupted health service delivery, with women with maternal CMDs being particularly vulnerable to this public health crisis.

WITHDRAWN: Early identification of hypertensive disorders of pregnancy (An mhealth feasibility study for resource limited settings)

Hypertensive Disorders of Pregnancy (HDP) account for 18% of potential preventable maternal deaths in South Africa. MHealth studies on early HDP identification in high income countries showed potential value for limited resource settings. This study aimed to test the feasibility of an mHealth solution for early identification of HDP using self home monitoring of blood pressure (BP) and sharing of information on symptoms of preeclampsia in a low middle income country (LMIC). This mixed methods study, enrolled 100 pregnant women (20 to 30 weeks) to selfmonitor and submit daily BP and pulse readings on a smart phone to an mHealth platform observed by a midwife for targeted action. Information was shared on 7 symptoms of preeclampsia using brochures, posters, targeted digital messages and quizzes. Study data was collected through the mHealth platform, key informant interviews, pre pand post knowledge, attitude and practice (KAP) suveys and self and community health worker’s (CHW) reported outcomes. Ten cases had interventions for HDP in the cohort. All mothers with HDP and their babies had satisfactory outcomes. This was facilitated through the BP monitoring on the App and digital platform, increased knowledge of 7 symptoms of preeclampsia and CHW follow up. The study found in conclusion that pregnant women in resource limited settings are able to self home monitor their BP using a mHealth solution for early identification and management of HDP. The study acknowledge challenges for scale up and cost effectiveness but recognise potential.

Pregnant women\u2019s experiences with the management of hypertensive disorders of pregnancy: a qualitative study

BackgroundHypertensive disorders are a leading cause of mortality and morbidity during pregnancy. Despite multiple national and international clinical guidelines and a plethora of research in the field of optimising management, there has been limited research describing the perspectives and experiences of pregnant women with the management of hypertensive disorders of pregnancy (HDP). Understanding these perceptions and experiences is imperative to the optimisation of HDP management.MethodsA qualitative study involving face-to-face, in-depth interviews were undertaken with 27 pregnant women diagnosed with and being treated for HDP to explore their perspectives of and experiences with clinical management. Written consent was obtained individually from each participant, and the interviews ranged from 16 to 54 min. Inductive codes were generated systematically for the entire data set. Line-by-line analysis was then performed and nodes were created within NVivo, a qualitative data management software. Data collection was continued until thematic saturation was reached. Thematic analysis was employed to interpret the data.ResultsThree major descriptive themes were discerned regarding the women’s perspectives on and experiences with the management of HDP: attitudes towards monitoring of HDP, attitudes and perceptions towards development and management of complications, and perceptions of pregnant women with chronic hypertension. Trust in the hospital system, positive attitudes towards close blood pressure monitoring as well as self-monitoring of blood pressure, and a realistic approach to emergency antenatal hospital admissions contributed to a positive attitude towards monitoring of HDP. Women with prior experiences of HDP complications, including pre-eclampsia, were more confident in their clinical management and knew what to expect. Those without prior experience were often in shock when they developed pre-eclampsia. Some women with chronic hypertension displayed limited understanding of the potential risks that they may experience during pregnancy and thus lacked comprehension of the seriousness of the condition.ConclusionsThe clinical management experiences of pregnant women with HDP were varied. Many women did not feel that they were well informed of management decisions and had a desire to be more informed and involved in decision-making. Clear, concise information about various facets of HDP management including blood pressure monitoring, prescription of the appropriate antihypertensive agent, and planning for potential early delivery are required.

Perinatal outcomes of women with hypertensive disorders of pregnancy in Jimma Medical Center, southwest Ethiopia: Retrospective cohort study.

BackgroundHypertensive disorders of pregnancy (HDP) increases adverse perinatal outcomes in women with the disorder. About 16% of all still births and 10% of early neonatal deaths are accounted by HDP. In Ethiopia, HDP complicates about 6% of all pregnancies. Hence, the objective of this study was to determine the risk of adverse perinatal outcomes among women with HDP in Jimma Medical Center, southwest Ethiopia.MethodsA retrospective cohort study was conducted on a total of 777 women who gave birth from June 2017 to March 2020 at Jimma Medical Center, southwest Ethiopia. Women with HDP and normotensive women who gave birth at or after 28 weeks of gestation were enrolled as exposed and unexposed respectively. Simple random sampling technique was used to select study participants. Data were reviewed using structured data collection performa that was prepared after reviewing relevant literatures. Data were entered to Epi-Data then exported to STATA version 13 for analysis. The adverse perinatal outcomes risk were examined using log binomial and modified Poisson regression model with robust standard errors.ResultsIn this study, the overall incidence of adverse perinatal outcome was higher among women with hypertensive disorders of pregnancy (HDP) than normotensive women (64.1% versus 32.8%). After adjusting for confounders, women with HDP were at higher risk of babies with low birth weight (adjusted RR = 2.88 (2.2, 3.75)), preterm birth(aRR = 2.31(1.7, 3.14)), fifth minute low Apgar score (aRR = 2.6(1.53, 4.42)), admission to neonatal intensive care unit (aRR = 1.77(1.32, 2.37), stillbirth (aRR = 2.02(1.11, 3.01)), and perinatal mortality (aRR = 3.88(1.97, 7.66)) than normotensive women.ConclusionWomen with hypertensive disorder of pregnancy were at higher risk of adverse perinatal outcomes than normotensive women who gave birth at Jimma Medical Center, southwest Ethiopia. Therefore, health care providers should strengthen prevention, early diagnosis and prompt management of HDP in order to reduce adverse perinatal outcomes.

Challenging the status quo: results of an acceptability and feasibility study of hypertensive disorders of pregnancy (HDP) management pathways in Indonesian primary care

BackgroundHypertensive disorders of pregnancy (HDP) are the leading cause of maternal mortality in Indonesia. Focused HDP management pathways for Indonesian primary care practice have been developed from a consensus development process. However, the acceptability and feasibility of the pathways in practice have not been explored. This study reports on the implementation process of the pathways to determine their acceptability and feasibility in Indonesian practice.MethodsThe pathways were implemented in three public primary care clinics (Puskesmas) in Yogyakarta province for a month, guided by implementation science frameworks of Medical Research Council (MRC) and the Practical Robust Implementation and Sustainability Model (PRISM). The participating providers (general practitioners (GPs), midwives, and nurses) were asked to use recommendations in the pathways for a month. The pathway implementation evaluations were then conducted using clinical audits and a triangulation of observations, focus groups (FGs), and interviews with all of the participants. Clinical audit data were analysed descriptively, and qualitative data were analysed using a mix of the inductive-deductive approach of thematic analysis.ResultsA total of 50 primary care providers, four obstetricians, a maternal division officer in the local health office and 61 patients agreed to participate, and 48 of the recruited participants participated in evaluation FGs or interviews. All of the providers in the Puskesmas attempted to apply recommendations from the pathways to various degrees, mainly adopting preeclampsia risk factor screenings and HDP monitoring. The participants expressed that the recommendations empowered their practice when it came to HDP management. However, their practices were challenged by professional boundaries and hierarchical barriers among health care professionals, limited clinical resources, and regulations from the local health office. Suggestions for future scale-up studies were also mentioned, such as involving champion obstetricians and providing more patient education toolkits.ConclusionThe HDP management pathways are acceptable and feasible in Indonesian primary care. A further scale-up study is desired and can be initiated with investigations to minimise the implementation challenges and enhance the pathways’ value in primary care practice.

Hypertensive disorders of pregnancy (HDP) management pathways: results of a Delphi survey to contextualise international recommendations for Indonesian primary care settings

BackgroundHypertensive disorders of pregnancy (HDP) are a significant contributor to the high maternal mortality rate in Indonesia. At the moment, limited guidelines are available to assist primary care providers in managing HDP cases. A previous review of 16 international HDP guidelines has identified opportunities for improving HDP management in Indonesian primary care, but it has not determined the suitability of the recommendations in practice. This study aims to achieve consensus among the experts regarding the recommendations suitability and to develop HDP pathways in Indonesian primary care.MethodsMaternal health experts, including GPs, midwives, nurses, medical specialists and health policy researchers from Indonesia and overseas were recruited for the study. They participated in a consensus development process that applied a mix of quantitative and qualitative questions in three Delphi survey rounds. At the first and second-round survey, the participants were asked to rate their agreement on whether each of 125 statements about HDP and HDP management is appropriate for use in Indonesian primary care settings. The third-round survey presented the drafts of HDP pathways and sought participants’ agreement and further suggestions. The participants’ agreement scores were calculated with a statement needing a minimum of 70% agreement to be included in the HDP pathways. The participants’ responses and suggestions to the free text questions were analysed thematically.ResultsA total of 52 participants were included, with 48, 45 and 37 of them completing the first, second and third round of the survey respectively. Consensus was reached for 115 of the 125 statements on HDP definition, screening, management and long-term follow-up. Agreement scores for the statements ranged from 70.8–100.0%, and potential implementation barriers of the pathways were identified. Drafts of HDP management pathways were also agreed upon and received suggestions from the participants.ConclusionsMost evidence-based management recommendations achieved consensus and were included in the developed HDP management pathways, which can potentially be implemented in Indonesian settings. Further investigations are needed to explore the acceptability and feasibility of the developed HDP pathways in primary care practice.

801 Hypertensive disorders of pregnancy in a pandemic: care delivery, outcomes, and lessons learned

To investigate outcomes in hypertensive disorders of pregnancy (HDP) with regard to shifting care models during the COVID-19 pandemic. We retrospectively compared women with complete records and without a major fetal anomaly diagnosed with HDP at a tertiary care center during the COVID-19 pandemic (April 2020) to women meeting the same criteria one year prior (April 2019). In the setting of a high regional COVID case load, women were offered virtual care, home BP monitoring was encouraged, and those with HDP had expedited discharges home with close follow up by phone from medical student volunteers on postpartum days 3, 5, and 7. The primary outcome was severity of HDP subtype at presentation. Secondary outcomes included diagnosis/delivery gestational age, NICU admission, time from last prenatal care visit to delivery, diagnosis site, and postpartum readmission. 229 women met criteria for analysis, 119 (52.0%) delivering pre-COVID and 110 (48.0%) during COVID. Individuals delivering in the two time periods had similar demographics and major co-morbidities, though patients had more in-person prenatal and postpartum visits before the pandemic (P<0.01, Table 1). There was no difference in the distribution of HDP severity, diagnosis site, or diagnosis timing across timepoints (Table 2). Likewise, there was no difference in the site of prenatal visit or time from last prenatal care visit to delivery. Gestational ages at delivery and NICU admission rates were also similar between timepoints. However, the post-partum readmission rate was higher in peri-pandemic time, with 4.2% needing readmission pre-COVID compared to 17.3% peri-COVID. Though changes in prenatal care did not affect the severity of women’s HDP presentation during the COVID pandemic, there were higher rates of postpartum readmission for HDP management. This may be due to truncated in-hospital monitoring periods, increased surveillance from medical student follow up, or difficulty managing blood pressure as an outpatient postpartum. These findings may help providers critically evaluate care models for HDP.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Using whiteboard videos to raise awareness of hypertension in pregnancy: design and user testing of a patient education resource

Hypertensive disorders of pregnancy (HDP) complicate 10% of pregnancies worldwide. The detrimental effects of HDP extend beyond the perinatal period; they confer lifelong increased risk of cardiometabolic disease and stroke for mothers. The objective of this research project is to create whiteboard animations that educate patients about the prevention and management of HDP.