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

OBJECTIVE: To investigate blood pressure changes from preconception to 42-day postpartum in patients with gestational hypertension, preeclampsia, and chronic hypertension. STUDY DESIGN: Secondary analysis of patients diagnosed with a hypertensive disorder of pregnancy (HDP) antenatally or postpartum, who were enrolled prospectively in a postpartum remote blood pressure (BP) monitoring program between March 2017 and May 2020. BP were collected at 47 time points: preconception, each trimester, delivery day, and every postpartum day through 42-days postpartum. The primary outcome of the study was to examine changes in BP over time and between the types of HDP for 42 days postpartum. Secondary outcomes included the difference in timing of BP stabilization (BPs < 140/90 mmHg for ≥ 48 h), BP resolution (stabilized without antihypertensive medication use), and antihypertensive medication usage at 42-day postpartum between the HDP groups. RESULTS: A total of 1,194 patients were included in the cohort; 224 (18.8 %) had chronic hypertension (CHTN), 525 (43.9 %) had gestational hypertension (GHTN), 153 (12.8 %) had preeclampsia, and 292 (24.5 %) had preeclampsia with severe features. Postpartum BP peaked on days 5-7 postpartum with rapid decrease from postpartum day 7 until postpartum day 14, followed by very small resolution/stabilization in BP values between day 15 and 42 postpartum. By 6 weeks postpartum, 60.5 % of patients with CHTN still required antihypertensive medications to maintain BP < 140/90 mmHg. In the group of patients with preeclampsia with severe features, 32.6 % still required antihypertensive medications to maintain BP < 140/90 mmHg. Finally, 16.1 % patients with GHTN and 23.8 % of patients with preeclampsia without severe features required antihypertensive use at 6 weeks postpartum. The groups of CHTN and GHTN had significant reduction in SBPs at 42-days postpartum compared to their pre-conception BP (p < 0.001 for both groups). While diastolic BP at 42-days postpartum were not different in CHTN, GHTN and preeclampsia groups, compared to preconception, women with preeclampsia with severe features had higher diastolic BP at the end of 6-weeks postpartum period compared to preconception readings (p = 0.007). CONCLUSION: Our study adds new information by examining BP trajectories through 42 days postpartum and demonstrates that all types of HDP are at risk of BP spikes and intervention through 42 days postpartum. We found that patients with CHTN had slower stabilization and resolution of their BP compared to patients with GHTN and preeclampsia with and without severe features. In addition, even at 42 days postpartum, a substantial proportion of patients with HDP, including GHTN, required antihypertensive treatment to maintain BP within stage I hypertension.

Serum Ferritin Threshold for Iron Deficiency Screening in One-Year-Old Children.

The American Academy of Pediatrics recommends universal hemoglobin screening for iron deficiency anemia using hemoglobin <110 g/L at the 1-year-old well child visit. Our retrospective study suggests the need for combined hemoglobin and serum ferritin iron deficiency screening and raising the diagnostic serum ferritin threshold to 24-25 µg/L.

International urogynecology consultation chapter 1 committee 2: Epidemiology of pelvic organ prolapse: prevalence, incidence, natural history, and service needs.

INTRODUCTION AND HYPOTHESIS: This narrative review describes the existing epidemiologic literature and identifies gaps regarding pelvic organ prolapse (POP) prevalence, incidence, natural history, and current and future service needs. MATERIALS AND METHODS: A PubMed search identified relevant citations published in 2000 or later. Pre-specified criteria were used to screen titles, abstracts, and manuscripts, including reference sections. Study findings were summarized to define what is known, identify gaps in current knowledge, and suggest priority areas for future research. RESULTS: The reported prevalence of POP varies widely (1-65%) based on whether its presence is ascertained by symptoms (1-31%), pelvic examination (10-50%), or both (20-65%). Most existing population-based surveys do not include physical examination data. White women from higher income countries are overrepresented in the existing literature. Incidence and natural history data are limited and consist mainly of cohorts that follow women after pregnancy or menopause. Given global increases in aging populations in well-resourced countries, the need for POP treatment is anticipated to increase in the coming decades. In lower and middle income countries (LMICs) where demographic trends are different, there is a dearth of information about anticipated POP service needs. CONCLUSION: Future POP incidence, prevalence, and natural history studies should include non-white women from LMICs and should combine pelvic examination data with validated patient-reported outcome measures when feasible. Anticipated future service needs differ globally, with a greater demand for POP treatment services in well-resourced settings where aging populations are prevalent.

Cost-effectiveness of telehealth with remote patient monitoring for postpartum hypertension.

OBJECTIVE: Evaluate cost-effectiveness of telehealth with remote monitoring for postpartum hypertensive disorders from the hospital's perspective. METHODS: A decision tree was developed using results from a non-randomized controlled trial comparing telehealth to standard outpatient blood pressure monitoring. At discharge, postpartum women with a hypertensive disorder received a Bluetooth tablet, blood pressure monitor, and scale to submit vitals daily for 6 weeks. Women were managed and treated with a standard protocol. We performed a cost-effectiveness analysis using data from the hospital, device manufacturer supplied charges, and utilities. A cost-effectiveness threshold was set at $100,000/quality-adjusted life years. One-way and two-way sensitivity analyses were performed to evaluate the robustness of our results compared to baseline assumptions. RESULTS: Telehealth monitoring significantly reduced postpartum readmissions, 3.7% (8/214) versus 0.5% (1/214), and resulted in higher quality-adjusted life years. Telehealth monitoring was cost-effective and cost-saving. Average cost of telehealth per patient was $309, and was cost-effective to a cost of $420 per patient. Telehealth monitoring remained cost-effective down to an admission cost of $10,999 compared to our baseline-estimate for the average admission cost of $14,401. Telehealth monitoring also remained cost-effective when the postpartum readmission rate was 3.0% or higher with standard monitoring. With a cost saving of $93 per patient and an estimated 333,253 pregnant women with hypertension in the US a year, telehealth could reduce health care costs in the US by approximately $31 million a year. CONCLUSIONS: This study demonstrates telehealth with remote blood pressure monitoring may be a cost-effective and cost-saving solution for management of postpartum hypertension.

Longitudinal blood pressure patterns of women with hypertensive disorders of pregnancy: preconception through postpartum.

OBJECTIVE: To investigate the longitudinal blood pressure (BP) pattern of women with hypertensive disorders of pregnancy (HDP) preconception through the postpartum day (PPD) 42. STUDY DESIGN: A retrospective study of women (≥15 years old) diagnosed with an HDP antenatally or postpartum, who were enrolled prospectively in a postpartum remote BP monitoring program between 3/2017 and 5/2020. BPs were collected from 47-time points: preconception, each trimester, delivery day, and 42 days postpartum. Analysis was conducted utilizing a mixed-effects longitudinal model. MAIN OUTCOME MEASURES: Primary outcome was the longitudinal BP patterns. Secondary outcomes were the timing of BP stabilization (BPs < 140/90 mmHg for ≥48 h) and resolution (stabilized without antihypertensive medication use). RESULTS: Our final analysis included 897 of the 964 eligible women. The peak systolic and diastolic BPs were on PPDs 3, 4, 5, and 5, 6, 7, respectively. Systolic BP fell below the preconception level after PPD15; diastolic BP reached its plateau after PPD17 and remained above the preconception level till PPD42 (p < .001). Postpartum BP peaked with the highest percentage of BP spikes on PPDs 4-7. The median survival times to BP stabilization and resolution were PPDs 11 (95% CI: 10-12) and 23 (95% CI: 21-25), respectively. By PPD42, 91.0% and 74.1% of women achieved BP stabilization and resolution, respectively. CONCLUSION: This study data could be used to develop evidence-based recommendations for women with an HDP. Diastolic BPs remaining significantly higher than the preconception level indicates the long-term risk of cardiovascular disease. In our cohort, 26% of women had unresolved hypertension by PPD42, which reinforces the necessity to ensure long-term follow-up.

Dose of aspirin to prevent preterm preeclampsia in women with moderate or high-risk factors: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of aspirin dose on the incidence of all gestational age preeclampsia and preterm preeclampsia. DATA SOURCES: Electronic databases (Cochrane, PubMed, Scopus, ClinicalTrials.gov and the Web of Science) were searched for articles published between January 1985 and March 2019 with no language restrictions. METHODS: We followed the PRIMSA guidelines and utilized Covidence software. Articles were screened by 2 independent reviewers, with discrepancies settled by an independent 3rd party. Study selection criteria were randomized trials comparing aspirin for prevention of all gestational age and preterm preeclampsia to placebo or no antiplatelet treatment in women aged 15-55 years with moderate or high-risk factors according to the list of risk factors from American College of Obstetricians and Gynecologists and United States Preventive Services Task Force guidelines. The quality of trials was assessed using the Cochrane risk of bias tool. The data were pooled using a random-effects meta-analysis comparing aspirin at doses of <81, 81, 100, and 150 mg. Pre-specified outcomes were all gestational age and preterm preeclampsia. RESULTS: Of 1,609 articles screened, 23 randomized trials, which included 32,370 women, fulfilled the inclusion criteria. In preterm preeclampsia, women assigned at random to 150 mg experienced a significant 62% reduction in risk of preterm preeclampsia (RR = 0.38; 95% CI: 0.20-0.72; P = 0.011). Aspirin doses <150 mg produced no significant reductions. The number needed to treat with 150 mg of aspirin was 39 (95% CI: 23-100). There was a maximum 30% reduction in risk of all gestational age preeclampsia at all aspirin doses. CONCLUSIONS: In this meta-analysis, based on indirect comparisons, aspirin at a dose greater than the current, recommended 81 mg was associated with the highest reduction in preterm preeclampsia. Our meta-analysis is limited due to the deficiency of homogeneous high evidence data available in the literature to date; however, it may be prudent for clinicians to consider that the optimal aspirin dose may be higher than the current guidelines advise. Future research to compare the efficacy aspirin doses greater than 81 mg is recommended. STUDY REGISTRATION: PROSPERO, CRD42019127951 (University of York, UK; http://www.crd.york.ac.uk/PROSPERO/).

Evaluation of different blood pressure assessment strategies and cutoff values to predict postpartum hypertension-related readmissions: a retrospective cohort study.

BACKGROUND: The American College of Obstetricians and Gynecologists suggests the initiation of postpartum antihypertensive treatment for women with hypertension in the postpartum period, a systolic blood pressure of ≥150 mm Hg or diastolic blood pressure of ≥100 mm Hg on 2 occasions at least 4 to 6 hours apart; however, the utility and validity of this strategy for preventing postpartum hypertension-related readmission remain unknown. OBJECTIVE: The primary objective was to evaluate the accuracy of different blood pressure assessment strategies for predicting postpartum hypertension-related readmissions. The secondary objective was to consider the impact of using different blood pressure thresholds for initiating postpartum antihypertensive treatment vs the impact of using the current blood pressure threshold recommended by the American College of Obstetricians and Gynecologists. STUDY DESIGN: A retrospective cohort study of 24,917 women who delivered at a single midwestern academic hospital between January 1, 2009, and June 30, 2015. Of those women, 3830 were identified as hypertensive, and 112 of 3830 women (2.92%) were readmitted for hypertension management. Blood pressures measured between delivery and 72 hours after delivery were used to evaluate 3 different blood pressure assessment strategies: average systolic or diastolic blood pressure exceeding the predetermined threshold (strategy 1), maximum systolic or diastolic blood pressure exceeding the predetermined threshold on 1 occasion (strategy 2), and maximum systolic or diastolic blood pressure exceeding the predetermined threshold on 2 occasions at least 4 hours apart (strategy 3). Analyzed blood pressure thresholds included all the integer blood pressure values between 100/50 mm Hg to 160/110 mm Hg for strategy 1 and 120/70 mm Hg to 190/140 mm Hg for strategies 2 and 3. The primary outcome was hypertension-related postpartum readmission. Receiver operating characteristic curves and the area under the curve were used to measure the predictive value of these strategies. RESULTS: The American College of Obstetricians and Gynecologists' recommendation of using blood pressure ≥150/100 mm Hg as a threshold had a sensitivity of 38% and specificity of 95%, whereas following strategy 3 and reducing the threshold to 140/90 mm Hg demonstrated a sensitivity of 71% and specificity of 84%. The area under the curve for the 3 strategies were as follows: strategy 1 (area under the curve, 0.81; 95% confidence interval, 76.95-85.08), strategy 2 (area under the curve, 0.79; 95% confidence interval, 74.70-82.81), and strategy 3 (area under the curve, 0.83; 95% confidence interval, 79.83-87.24). The difference between the areas under the curve of strategies 2 and 3 was statistically significant (P<.0001). CONCLUSION: The strategy of using the maximum systolic or diastolic blood pressure exceeding the blood pressure threshold on 2 occasions at least 4 hours apart at lower blood pressure thresholds can predict readmissions with higher sensitivity or specificity. Compared with the threshold of the American College of Obstetricians and Gynecologists' recommended blood pressure of ≥150/100 mm Hg, if the threshold for the postpartum antihypertensive treatment initiation was lowered to a blood pressure of ≥140/90 mm Hg, it would significantly reduce postpartum readmissions.

Enhanced Vascular Smooth Muscle Calcium Sensitivity and Loss of Endothelial Vasodilator Influence Contribute to Myogenic Tone Development in Rat Radial Uterine Arteries during Gestation.

Uterine artery myogenic tone (MT) develops during pregnancy in hemochorial placentates such as rats and humans. The physiological reason for its appearance is not clear, and we reasoned that it may be a late pregnancy (LP) event in preparation for controlling hemorrhage during parturition. We also hypothesized that gestational increases in RhoA-induced vascular smooth muscle (VSM) calcium sensitivity are contributory and occur under the tonic influence of nitric oxide (NO). Second-order pre-placental radial arteries from early-pregnant (day 12, n = 5), mid-pregnant (day 16, n = 5) and LP (day 20, n = 20) rats were used in combination with arteriography, VSM calcium measurements, pharmacological RHO/Rho-associated protein kinase (ROCK) and nitric oxide synthase (NOS) inhibition, and Western blotting. A subgroup of LP animals (LP + LN; n = 5) treated with L-NAME from gestational days 10 to 20 were used to determine the effects of NOS inhibition on MT and RhoA expression. MT was evident throughout pregnancy, but its expression in pressurized vessels was masked by endothelial NO-induced vasodilation during early gestation. RhoA protein expression was upregulated in LP and attenuated by in vivo NOS inhibition (as was MT). In vitro RHO/ROCK inhibition decreased MT in a concentration-dependent manner without reducing VSM calcium. In summary, pressure-dependent uterine artery tone increases with gestational age due to a combination of RhoA-mediated increases in VSM calcium sensitivity and a loss of endothelial NO influence.