Postpartum Blood Pressure Research Articles

Does Timing of Diagnosis of Hypertensive Disorders of Pregnancy Impact Blood Pressure Resolution?

Hypertensive disorders of pregnancy (HDP) can be diagnosed prior to labor, during labor, or postpartum. We evaluated whether the timing of HDP diagnosis impacts postpartum blood pressure (BP) outcomes. Secondary analysis of 384 patients with HDP from a trial evaluating furosemide use on BP outcomes. The timing of HDP diagnosis was categorized into diagnosis in the antepartum period, prior to labor versus diagnosis peripartum (during labor or first day of postpartum). Outcomes included time to resolution of hypertension and persistent hypertension 7 days' postpartum. Logistic and Cox regression models were used. Patients diagnosed in the peripartum period had a shorter median time to postpartum BP resolution after adjusting for severity of HDP, mode of delivery, and furosemide use (5.5 vs. 6.5 days, adjusted hazard ratio: 1.18, 95% confidence interval [1.11-1.25]). Patients diagnosed with HDP in the peripartum period experience a faster BP resolution than those diagnosed in the antepartum period. · HDP can be diagnosed before and during labor and postpartum.. · The timing of HDP diagnosis may have different implications for postpartum BP outcomes.. · Patients diagnosed with HDP in the peripartum period experienced a 24-hour shorter time to BP resolution.. · Timing of HDP diagnosis may provide an added window of opportunity to augment existing modalities of managing postpartum hypertension and related cardiovascular disease complications..

Intensive postpartum antihypertensive treatment (IPAT) and healthy lifestyle education: Study protocol for a pilot randomized controlled trial for patients with hypertensive disorders of pregnancy

BackgroundHypertensive disorders of pregnancy (HDP) complicate about 10 % of pregnancies and lead to postpartum hospital readmissions and cardiovascular complications. Following HDP, vascular dysfunction could persist and accelerate the trajectory of cardiovascular disease risk. The benefits of intensive blood pressure (BP) control following HDP have not been adequately investigated. Therefore, no standard guidelines exist to guide the management of mild-to-moderate hypertension in the postpartum period, leading to a wide variation in clinical practice. The present study will investigate the effect of intensive BP control and healthy lifestyle education on maternal cardiovascular health (CVH) and vascular function following HDP. MethodsThe Intensive Postpartum Antihypertensive Treatment (IPAT) study is a randomized controlled, two-arm, single-site, pilot trial where 60 postpartum HDP patients will be randomized 1:1 to one of two groups: 1) Intensive postpartum BP control – nifedipine initiation at BP ≥140/90 mmHg to maintain BP <140/90 mmHg; or 2) Less intensive postpartum BP control – nifedipine initiation at BP ≥150/100 mmHg to maintain BP <150/100 mmHg. All participants will also undergo vascular function assessments and receive healthy lifestyle education. The study will primarily test feasibility of all study procedures. It will secondarily examine changes in BP and CVH scores from baseline to 12 months postpartum. ConclusionThis pilot trial will study whether the BP threshold of 140/90 is superior to 150/100 for initiation of pharmacotherapy and evaluate feasibility to ultimately conduct a trial capable of generating robust evidence to standardize clinical practice and guidelines in postpartum HDP management.Trial registration number: NCT05687344

Physical Activity During Pregnancy And Postpartum Blood Pressure

Physical Activity During Pregnancy And Postpartum Blood Pressure

Effects of Antihypertensive Therapy During Pregnancy on Postpartum Blood Pressure Control.

To compare differences in postpartum blood pressure (BP) control (BP below 140/90 mm Hg) for participants with hypertension randomized to receive antihypertensive treatment compared with no treatment during pregnancy. This study was a planned secondary analysis of a multicenter, open-label, randomized controlled trial (The CHAP [Chronic Hypertension and Pregnancy] trial). Pregnant participants with mild chronic hypertension (BP below 160/105 mm Hg) were randomized into two groups: active (antihypertensive treatment) or control (no treatment unless severe hypertension, BP 160/105 mm Hg or higher). Study outcomes were BP control below 140/90 mm Hg (primary) and medication nonadherence based on a composite score threshold (secondary) at the 6-week postpartum follow-up visit. Participants without follow-up BP measurements were excluded from analysis of the BP control outcome. Participants without health care professional-prescribed antihypertensives at delivery were excluded from the analysis of the adherence outcome. Multivariable logistic regression was used to adjust for potential confounders. Of 2,408 participants, 1,684 (864 active, 820 control) were included in the analysis. A greater percentage of participants in the active group achieved BP control (56.7% vs 51.5%; adjusted odds ratio [aOR] 1.22, 95% CI, 1.00-1.48) than in the control group. Postpartum antihypertensive prescription was higher in the active group (81.7% vs 58.4%, P<.001), and nonadherence did not differ significantly between groups (aOR 0.81, 95% CI, 0.64-1.03). Antihypertensive treatment of mild chronic hypertension during pregnancy was associated with better BP control below 140/90 mm Hg in the immediate postpartum period.

Abstract P414: Association between postpartum sleep and blood pressure reduction in women with hypertensive disorders of pregnancy

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.

Abstract P190: Blood pressure monitoring and knowledge in the first year after a hypertensive disorder of pregnancy

Introduction: In the first year postpartum, hypertension (HTN) is a leading cause of morbidity and mortality, particularly for those with hypertensive disorders of pregnancy (HDP). Timely recognition of HTN is key to reducing short- and long-term cardiovascular risk among birthing people. Therefore, we assessed knowledge of when to seek medical attention for blood pressure (BP) elevations and rates of BP measurement in the first year postpartum among those with and without HDP. Methods: This was a secondary analysis of primiparas who participated in a randomized trial of prenatal counseling to improve postpartum health. We included 405 participants who self-reported information on postpartum BP assessment. We calculated (1) the proportion of participants who stated they would contact a clinician for a systolic BP above 140 and a diastolic BP above 90 at 3-months postpartum and (2) the frequency and location of BP checks reported from 3-12 months postpartum among those with and without HDP. Subgroup analyses compared BP knowledge by sociodemographic and health-related factors. Results: Participants were 32 +/-5 years, 16% reported a HDP, 60% identified as White, 75% had private insurance, and 84% had ≥ college education. For systolic BP, 44.6% with HDP and 23.5% without HDP identified a BP of 140 as the threshold above which they would contact a clinician (p&lt;0.01); for diastolic BP, 52.4% with HDP and 28.5% without identified a BP threshold of 90 (p&lt;0.01).From 3-12 months postpartum, 83.1% with HDP and 59.4% without HDP had a BP check (p &lt; 0.01); 41.6% with HDP and 9.7 % without HDP checked their BP at home (p&lt;0.01). Home monitoring was not associated with awareness of when to contact a physician for hypertension among those with HDP (TABLE). BP awareness was higher among people who had private health insurance, ≥ college education and were non-smokers. Conclusions: Efforts are needed to improve postpartum BP assessment, self-monitoring, and awareness of when to seek medical attention for HTN, among birthing people with and without HDP.

Expedited versus standard postpartum discharge in patients with hypertensive disorders of pregnancy and its effect on the postpartum course

BackgroundHospital stay after an uncomplicated delivery is typically 2 days for vaginal birth and 3 days for cesarean birth. Health maintenance organizations and third-party payers have encouraged shorter maternity stays. The safety of earlier discharge is unclear particularly when it comes to patients diagnosed with hypertensive disorders of pregnancy (HDP). ObjectiveTo examine whether expedited discharge amongst patients with HDP will have a negative effect on postpartum readmission rate and blood pressure related complications. Study designThis was a single academic center retrospective cohort study of patients with HDP (gestational hypertension, preeclampsia, or chronic hypertension) for 2 epochs: 2015–2018, prior to implementation of an expedited discharge policy, and 2019–2020 after hospital wide implementation of expedited postpartum discharge. The expedited discharge policy entailed patients being discharged home as soon as day 1 after a vaginal delivery and day 2 after a cesarean delivery. The primary outcome was unplanned health care utilization postpartum, defined as emergency department (ED) visits, unscheduled clinic visits, and hospital readmission. Secondary outcomes were planned postpartum visits attendance, antihypertensive medication initiation after discharge, and blood pressure control throughout the first year. Bivariable and multivariable logistic regression analyses were run to evaluate the association between expedited discharge and primary and secondary outcomes. ResultsA total of 1,441 patients were included in the analysis. There were no statistically significant differences in the rate of unplanned health care utilization (11.3% in the standard postpartum discharge group vs. 13.8% in the expedited discharge group, P=.17). Systolic and diastolic blood pressures did not differ between the groups at 1–2 weeks, six weeks, and one year postpartum. Patients in the expedited discharge group were more likely to attend the 1–2-week postpartum blood pressure check (58.7% vs. 51.7%, P=.02, adjusted OR 1.33, 95% CI 1.08–1.77). Other secondary outcomes did not differ between the two cohort groups. ConclusionIn this single academic center study, expedited discharge after delivery in patients with HDP was not associated with a higher rate of unplanned healthcare utilization postpartum.

Household Air Pollution and Postpartum Blood Pressure in the Ghana Randomized Air Pollution and Health Study

Household Air Pollution and Postpartum Blood Pressure in the Ghana Randomized Air Pollution and Health Study

Patterns of Antihypertensive Medication Use in the First 2 Years Post Partum

Women who had a hypertensive disorder of pregnancy (HDP) have a well-documented risk of chronic hypertension within a few years of delivery, but management of postpartum hypertension among these women remains inconsistent. To assess the incidence of initiation of antihypertensive medication use in the first 2 years after delivery by HDP status and antenatal antihypertensive medication use. This Danish register-based cohort study used data from women with at least 1 pregnancy lasting 20 or more gestational weeks (only the first pregnancy in the period was considered) who delivered from January 1, 1995, to December 31, 2018. Statistical analysis was conducted from October 2022 to September 2023. Hypertensive disorders of pregnancy. Cumulative incidences and hazard ratios of initiating antihypertensive medication use within 2 years post partum (5 postpartum time intervals) by HDP status and antenatal medication use. The cohort included 784 782 women, of whom 36 900 (4.7% [95% CI, 4.7%-4.8%]) had an HDP (HDP: median age at delivery, 29.1 years [IQR, 26.1-32.7 years]; no HDP: median age at delivery, 29.0 years [IQR, 25.9-32.3 years]). The 2-year cumulative incidence of initiating postpartum antihypertensive treatment ranged from 1.8% (95% CI, 1.8%-1.8%) among women who had not had HDPs to 44.1% (95% CI, 40.0%-48.2%) among women with severe preeclampsia who required antihypertensive medication during pregnancy. Most women who required postpartum antihypertensive medication after an HDP initiated use within 3 months of delivery (severe preeclampsia, 86.6% [95% CI, 84.6%-89.4%]; preeclampsia, 75.3% [95% CI, 73.8%-76.2%]; and gestational hypertension, 75.1% [95% CI, 72.9%-77.1%]). However, 13.4% (95% CI, 11.9%-14.1%) of women with severe preeclampsia, 24.7.% (95% CI, 24.0%-26.0%) of women with preeclampsia, 24.9% (95% CI, 22.5%-27.5%) of women with gestational hypertension, and 76.7% (95% CI, 76.3%-77.1%) of those without an HDP first filled a prescription for antihypertensive medication more than 3 months after delivery. Women with gestational hypertension had the highest rate of initiating medication after more than 1 year post partum, with 11.6% (95% CI, 10.0%-13.2%) starting treatment after this period. Among women who filled a prescription in the first 3 months post partum, up to 55.9% (95% CI, 46.2%-66.1%) required further prescriptions more than 3 months post partum, depending on HDP status and antenatal medication use. In this cohort study of postpartum women, the incidence of initiation of postnatal antihypertensive medication use varied by HDP status, HDP severity, and antenatal antihypertensive medication use. Up to 24.9% of women initiated antihypertensive medication use more than 3 months after an HDP, with up to 11.6% initiating treatment after 1 year. Routine postpartum blood pressure monitoring might prevent diagnostic delays in initiation of antihypertensive medication use and improve cardiovascular disease prevention among women.

Clinical Outcomes Associated With a Remote Postpartum Hypertension Monitoring Program.

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.

Postpartum Weight Change Association With Readmission and Blood Pressure Trend Among Individuals With Hypertensive Disorders of Pregnancy.

The aim of this study was to evaluate the association between early postpartum weight change and (1) hospital readmission and (2) 2-week blood pressure trajectory. This retrospective study cohort included 1365 individuals with a hypertensive disorder of pregnancy enrolled in a postpartum hypertension remote monitoring program. Exposure was percentage weight change from delivery to first weight recorded within 10 days postpartum. We first modeled likelihood of hospital readmission within 8 weeks postpartum using logistic regression adjusting for age, race, insurance, type of hypertensive disorder of pregnancy, early body mass index, gestational weight gain, mode of delivery, and any discharge antihypertensive medications. We then performed case-control analysis additionally matching in a 1:3 ratio on breastfeeding, early body mass index, discharge on antihypertensive medications, and days between weight measurements. Both analytic approaches were repeated, limiting to readmissions attributable to hypertension or heart failure. Finally, we compared blood pressure trajectories over first 2 weeks postpartum. Individuals who did not lose weight in the early postpartum period had more admissions compared with weight loss groups (group 3: 14.1% versus group 2: 5.8% versus group 1: 4.5%). These individuals had 4 times the odds of postpartum readmissions (adjusted odds ratio [aOR], 3.9 [95% CI, 1.8-8.6]) to 7 (aOR, 7.8 [95% CI, 2.3-26.5]) compared with those with the most weight loss. This association strengthened when limited to hypertension or heart failure readmissions. These individuals also had more adverse postpartum blood pressure trajectories, with significant differences by weight change group. Weight change is readily accessible and may identify individuals at high risk for postpartum readmission following a hypertensive disorder of pregnancy who could benefit from targeted interventions.

Incorporating Maternal Blood Pressure Screening Into Routine Newborn Clinic Visits

Background and ObjectivesIn the immediate postpartum period, mothers often prioritize newborn care over postpartum follow-up. There is an increasing contribution of hypertensive disorders of pregnancy (HDP) to maternal morbidity and mortality. In this feasibility study, we sought to implement maternal postpartum blood pressure (BP) screening in a newborn clinic. MethodsWe conducted a non-randomized, prospective feasibility study to evaluate the application of maternal BP screening at newborn clinic visits. An elevated BP was defined as a systolic pressure (SBP) of ≥140 mmHg or a diastolic pressure (DBP) of ≥90 mmHg. BPs were triaged with a standardized algorithm, utilizing support and expertise of on-call maternal subspecialists. ResultsWe screened 72 postpartum individuals, with a mean SBP of 130±19 mmHg and DBP 86±12 mmHg. Most were publicly insured (78%) and self-identified as Black (69%). Of the 31 (43%) with an elevated BP, 13 (42%) did not have a known HDP. Of those without known HDP, 4 were diagnosed with postpartum preeclampsia and 2 with postpartum hypertension. One individual diagnosed with new-onset postpartum preeclampsia was triaged to the emergency department. Only 56% of women attended a obstetrics appointment within 12 weeks after delivery. ConclusionsThis study demonstrates the feasibility of an innovative maternal postpartum BP assessment in a racially and socioeconomically diverse pediatrics clinic. Through collaborative care, individuals were able to be safely triaged, thus providing an opportunity to identify at-risk individuals who could benefit from earlier identification and management of hypertension. Pediatricians have a unique opportunity to contribute to postpartum maternal health.

Postpartum Ambulatory Blood Pressure Patterns Following New-Onset 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.

Ensuring safe and equitable discharge: a quality improvement initiative for individuals with hypertensive disorders of pregnancy

ObjectiveTo improve timely and equitable access to postpartum blood pressure (BP) monitoring in individuals with hypertensive disorders of pregnancy (HDP).MethodsA quality improvement initiative was implemented at a large academic medical...

A HIGHER BLOOD PRESSURE DURING EARLY PREGNANCY IN WOMEN WITH PREECLAMPSIA PREDICTS CHRONIC HYPERTENSION

Objective: Preeclampsia affects 2-8% of pregnancies and although it resolves after delivery, women still face a 2- to 6- fold higher risk of chronic hypertension and cardiovascular disease. Early identification of these high-risk women and personalized interventions will mitigate these risks. However, reliable predictors of chronic hypertension after preeclampsia are lacking. We aimed to analyze blood pressure patterns during pregnancy in women with preeclampsia in relation to chronic hypertension 1-3 years postpartum. Design and method: This study combines data from the Rotterdam Periconception Cohort and the Follow-up After Preeclampsia Outpatient Clinic cohort, two prospective cohorts embedded in patient care. Women with preeclampsia who were treated at the Erasmus Medical Center between 2010 and 2022 and had follow-up visits 1 and/or 3 years after pregnancy were included. Maternal characteristics, pregnancy outcomes and blood pressure measurements from the first trimester of pregnancy up to the first week postpartum were obtained from electronic health records and study databases. Chronic hypertension was defined as blood pressure &gt;140/&gt;90 mmHg or use of antihypertensive drugs at one or both follow-up visits. We used linear mixed regression models for analysis of blood pressure patterns throughout pregnancy. Additionally, we analyzed postpartum antihypertensive drug use utilizing standardized Defined Daily Doses. Results: Chronic hypertension was present in 39 of 72 patients included (54.2%). A significantly higher blood pressure was observed between week 8 and 24 of pregnancy in women with chronic hypertension at follow-up, with the largest difference in systolic blood pressure at week 18: 131 mmHg vs. 117 mmHg. While postpartum blood pressure patterns were comparable among groups, women with chronic hypertension at follow-up used higher doses of antihypertensive drugs during the first 5 days after delivery (mean difference 1.44 dose, p&lt;0.001). Conclusions: Women that develop chronic hypertension within 3 years after a pregnancy complicated with preeclampsia have higher blood pressures and a distinctive blood pressure pattern up to 24 weeks of gestation, compared to women who do not develop chronic hypertension. The patterns presented in this study are promising predictors of chronic hypertension and warrant further validation.

Postpartum blood pressure control and the rate of readmission

Postpartum hypertension is a major contributor to the rising maternal mortality rates in the United States, with nearly half of maternal deaths occurring after delivery. Previous studies have found evidence that the maximum blood pressure reading during labor and delivery admission can predict readmission; however, the optimal blood pressure to reduce the need for readmissions and additional medical treatment in the postpartum period is not known. This study aimed to investigate the relationship between postpartum blood pressure control at discharge and readmission within the first 6 weeks after delivery. Data were obtained from Cosmos, an electronic health record-based, Health Insurance Portability and Accountability Act-defined limited dataset that includes more than 1.4 million birth encounters. All birthing parents with blood pressure data after delivery were included. Demographic information, medications, and readmissions were queried from the dataset. Patients were grouped into categories based on blood pressure readings in the 24 hours before discharge (≥160/110, ≥150/100, ≥140/90, ≥130/80, ≥120/80, and <120/80 mm Hg). The readmission rates across these groups were compared. Planned subanalyses included stratification by the use of antihypertensive medications and a sensitivity analysis using the highest blood pressure during admission. Covariates included maternal age, preexisting diabetes mellitus or lupus erythematosus, and body mass index. The analysis included 1,265,766 total birth encounters, 391,781 (30.9%) in the referent group (120/80 mm Hg), 392,592 (31.0%) in the group with <120/80 mm Hg, 249,414 (19.7%) in the group with ≥130/80 mm Hg, 16,125 (1.3%) in the group with ≥140/90 mm Hg, 50,659 (4.0%) in the group with ≥150/100 mm Hg, and 20,196 (1.6%) in the group with ≥160/110 mm Hg. In the first 6 weeks after delivery, readmission rates increased with higher blood pressure readings. More than 5% of postpartum patients with the highest blood pressure readings (≥160/110 mm Hg) were readmitted. These patients were almost 3 times more likely to be readmitted than patients whose highest blood pressure reading fell into the referent group (120/80 mm Hg) (odds ratio [OR], 2.90; 95% confidence interval, 2.69-3.12). Patients with blood pressures of >150/100 mm Hg (odds ratio, 2.72; 95% confidence interval, 2.58-2.87), >140/90 mm Hg (odds ratio, 2.03; 95% confidence interval, 1.95-2.11), and >130/80 mm Hg (odds ratio, 1.43; 95% confidence interval, 1.37-1.49) all had higher odds of readmission, whereas patients with a blood pressure of <120/80 mm Hg had a lower odds of readmission (odds ratio, 0.78; 95% confidence interval, 0.75-0.81). Patients who had higher blood pressures during admission but had improved control in the 24 hours before discharge had lower rates of readmission than those whose blood pressures remained elevated. In all blood pressure categories, patients who received an antihypertensive prescription had higher rates of readmission. In this large, national dataset, blood pressure control at discharge and readmission in the postpartum period were significantly correlated. Our data should inform postpartum hypertension treatment goals and the role of remote monitoring programs in improving maternal safety.

Effect of pre-eclampsia on lactogenesis: Breastfeeding and the effect of breastfeeding on women's postpartum blood pressure

Preeclampsia is a serious complication of pregnancy, affecting 3 to 8% of all pregnancies and endangering both the pregnant woman and the fetus. The predominant etiological origin of preeclampsia has been shown to result from abnormal placentation, leading to abnormal remodeling of the spiral arteries and placental ischemia. The placenta plays an important role in pregnancy as it produces a multitude of hormones which are necessary for the maintenance of women's physiology, the development of embryos and also for the promotion of the developed mammary epithelium, so that breastfeeding becomes possible postnatally. Human breast milk is the most valuable nutritional source for infants. Women with preeclampsia more often have problems with lactogenesis II and breastfeeding than women without. It appears that the effect of preeclampsia on breastfeeding is multifactorial in nature and that a strong predictor of breastfeeding outcome is women's intention to breastfeed. Women with hypertensive disorders breastfeed for a shorter period of time and use the formula more easily. Breastfeeding appears to be protectively associated with blood pressure in later life in women, and the shortest duration of breastfeeding associated with benefit is one month. Further investigations are needed to elucidate the mechanism of delayed galactogenesis II in the presence of preeclampsia. Education about the benefits of breastfeeding to prevent hypertension in women is a low-risk intervention and may have a positive impact on cardiovascular outcomes in mothers over time.

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

ObjectiveThis 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 DesignThis 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 MeasuresThe 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. ResultsMedian 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). ConclusionIn 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.

Early postpartum blood pressure screening is associated with increased detection of cardiovascular risk factors in women with hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP), including gestational hypertension, preeclampsia, and eclampsia, are risk factors for cardiovascular (CV) disease. Guidelines recommend that women with HDP be screened for the development of hypertension (HTN) within 6-12 months postpartum. However, the extent to which this early blood pressure (BP) screening is being performed and the impact on detection of CV risk factors is unknown. Women with HDP and without pre-existing hypertension (HTN) who had at least 6 months of clinical follow-up were categorized by postpartum BP screening status: early BP screen (6-12 months after delivery) or late BP screen (≥12 months after delivery). Multivariable logistic regression identified factors associated with early screening. Multivariable Cox proportional hazards modeling examined the association between early screening and detection of incident CV risk factors: HTN, prediabetes, diabetes mellitus type 2, or hyperlipidemia. Among 4194 women with HDP, 1172 (28%) received early BP screening. Older age, pre-existing hyperlipidemia, diabetes, sickle cell disease, hypothyroidism, gestational diabetes, and delivery during or after 2014 were independently associated with early BP screening, whereas Hispanic ethnicity was associated with late BP screening. Early BP screening was most commonly performed at a primary care visit. After a median follow-up of 3.7 years, 1012 (24%) women had at least 1 new risk factor detected. Even after adjustment for baseline risk, women receiving early BP screening had a significantly higher rate of incident CV risk factor detection than women receiving late BP screening (56% vs 28%; adj. HR 2.70, 95%CI: 2.33-3.23, P < .001). Early postpartum BP screening was performed in a minority of women with HDP, but was associated with greater detection of CV risk factors. More intensive postpartum CV screening and targeted interventions are needed to optimize CV health in this high-risk population of women with HDP.

Longitudinal Management of Cardiovascular Risk Factors Among Postpartum Women.

Background: Pregnancy-related cardiovascular (CV) conditions, including hypertensive disorders of pregnancy (HDP) and gestational diabetes (GDM), are associated with increased long-term CV risk. Methods: This retrospective cohort study defined the prevalence of HDP and GDM within a large, academic health system in the southeast United States between 2012 and 2015 and described health care utilization and routine CV screening up to 1-year following delivery among those with pregnancy-related CV conditions. Rates of follow-up visits and blood pressure, hemoglobin A1c (HbA1c), and lipid screening in the first postpartum year were compared by provider type and pregnancy-related CV condition. Results: Of the 6027 deliveries included, 20% were complicated by HDP and/or GDM. Rates of pre-pregnancy CV risk factors were high, with a significantly higher proportion of pre-pregnancy obesity among women with HDP than in normal pregnancies. Those with both HDP/GDM had the highest rates of follow-up by 1-year postpartum, yet only half of those with any pregnancy-related CV condition had any follow-up visit after 12 weeks. Although most (70%) of those with HDP had postpartum blood pressure screening, less than one-third of those with GDM had a repeat HbA1c by 12 months. Overall, postpartum lipid screening was rare (<20%). Conclusion: There is a high burden of pregnancy-related CV conditions in a large U.S. academic health system. Although overall rates of follow-up in the early postpartum period were high, gaps in longitudinal follow-up exist. Low rates of CV risk factor follow-up at 1 year indicate a missed opportunity for early CV prevention.