Hypertension Disorders of Pregnancy Largely Persist in the Postpartum Period

A cohort study of 2705 patients found that 81.8% of individuals with hypertensive disorders of pregnancy (HDP; preeclampsia or gestational hypertension) had ongoing hypertension after hospital discharge, with 14.1% developing severe hypertension. Patients with severe hypertension were more likely to be admitted to the emergency department during the postpartum period (adjusted OR [aOR], 1.85; 95% CI, 1.17-2.92) and readmitted to the hospital (aOR, 6.75; 95% CI, 3.43-13.29) compared with individualss with normalized blood pressure (BP).

Study participants were enrolled in a remote BP management program at a postpartum unit at a referral hospital and delivered between September 2019 and June 2021. The study, published in JAMA Cardiology,¹ employed real-time home BP measures. Study participants had no prepregnancy hypertension, a mean age of 29.8 years, and a median early pregnancy body mass index of 29.8.

“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,” the authors wrote.

Inpatient postpartum BP categories were compared with outpatient home BP trajectories to help determine optimal thresholds for inpatient antihypertensive medication initiation. There was significant overlap between postdischarge BP trajectories among those with inpatient systolic BP of at least 140 to 149 mm Hg and/or diastolic BP of at least 90 to 99 mm Hg, and those with systolic BP of at least 150 mm Hg and/or diastolic BP of at least 100 mm Hg, the study authors said.

Maternal morbidity and mortality, which mostly occur in the postpartum period, are increasing at an alarming rate in the US, according to the study. Up to 20% of pregnant patients are hypertensive, and hypertension is a significant driver of maternal morbidity and mortality in the postpartum period. Hypertension is the most common reason for postpartum hospital readmission, yet there exists a lack of clear guidelines on optimal BP management, and risk factors for ongoing hypertension have not been well characterized.

“There’s really a lack of knowledge for people with high blood pressure in pregnancy, what happens with blood pressure after they leave the hospital,” said the study’s principal author, Alisse Hauspurg, MD, assistant professor, Department of Obstetrics, Gynecology & Reproductive Sciences at the University of Pittsburgh, in an interview with The American Journal of Managed Care^®. “We tell them to come into the office 10 days or so after the delivery. The issue with that is there are a lot of competing priorities for the postpartum period. People often prioritize newborn health, and maternal health is often deprioritized. Less than 50% of patients actually come in. Because of that, there can be a lot of untreated hypertension."

Key strengths of the study include the sociodemographic diversity of the sample, with 18% who self-identified as Black race and 35% who reported use of public insurance at the delivery admission, provision of an automatic BP measurement device to all patients enrolled in the monitoring program, and recommendation of daily BP monitoring in the first 2 weeks, according to Sadiya S. Khan, MD, MSc, assistant professor of medicine (cardiology) and assistant professor of preventive medicine (epidemiology) at Northwestern University’s Feinberg School of Medicine.²

“Strategies that address upstream social determinants of health are urgently needed given the disproportionate burden of HDP, readmission after HDP, and lifetime risk of cardiovascular disease among minoritized individuals,” Khan wrote in an editorial in JAMA Cardiology.²

Hauspurg said, “There’s a lot to be done” from research and policy perspectives. Future studies should evaluate whether lower thresholds for medication initiation would lead to better outcomes. Advocacy on state and federal levels is needed to make remote BP management programs more accessible, by outfitting hospitals with these programs and covering BP cuffs for all postpartum people, she said.

“We’ve been rethinking the traditional ways of caring for people, because having them come into the office clearly isn't working,” she said.

References

1. Hauspurg A, Venkatakrishnan K, Collins L, et al. Postpartum ambulatory blood pressure patterns following new-onset hypertensive disorders of pregnancy.JAMA Cardiol.2024:e241389. doi:10.1001/jamacardio.2024.1389

2. Khan SS. Postpartum remote blood pressure monitoring—when control is of the essence. JAMA Cardiol. Published online June 12, 2024. doi:10.1001/jamacardio.2024.1386