A Comparison of Obstetric Interventions and Outcomes Between Black and White Patients at an Urban Tertiary Medical Center.

The objective of the study is to evaluate whether rates of selected labor and delivery interventions and severe maternal morbidity (SMM) differ between Black and White pregnant patients. This retrospective observational cohort study included all Black or White pregnant patients who delivered at the University of Chicago Medical Center between January 2015 and December 2019. Data queried included demographic information, antepartum complications, preterm interventions, labor and delivery events, and neonatal outcomes. SMM was a composite outcome, including intensive care unit admission, blood transfusion, hysterectomy, eclampsia, cardiac arrest, or death. In total, 10,885 parturients (9001 Black and 1884 White) and 11,211 neonates (9254 born to Black and 1957 to White patients) were included in the study. Black patients were more likely to have preterm labor (3.51% vs. 1.86%, p = 0.0002) and no prenatal care (17.83% vs. 4.05%, p < 0.0001). There was no significant difference in the administration of magnesium sulfate for fetal neuroprotection (Black 44.78% vs. White 49.32%, p = 0.48) or antenatal corticosteroids (Black 67.83% vs. White 71.98%, p = 0.28) among those with preterm delivery. There was no significant difference in SMM (Black 2.24% vs. White 2.44%, p = 0.60), and SMM rates decreased over time (OR 0.79 per year, 95% CI: 0.72-0.87, p < 0.0001) for all patients. Black patients had more pregnancy complications, but their complications were addressed with similar rates of obstetrical interventions. In a high-resource setting, there was no difference in rates of SMM when compared to White patients.

Women's perspectives and attitudes towards the utility of angiogenic biomarkers in preeclampsia.

OBJECTIVE: This study aimed to evaluate womens' perspectives about current and novel preeclampsia testing methods at an urban tertiary medical center. METHODS: This was an observational survey study conducted between October 1, 2020 and December 31, 2020. Subjects were eligible if they were ≥ 18 years of age and had a diagnosis of gestational hypertension, preeclampsia, or superimposed preeclampsia at the time of delivery. Informed consent was obtained, and the 26-question survey was administered after delivery. A detailed medical record review was completed for respondents (patients) and their neonates. RESULTS: A total of 100 women were included in the study. The majority of participants were Black (78%) and/or on Medicaid (51%). Most respondents agreed that they fully trust their doctor and medical team (96%) and that the newest medical tests, treatments, and technologies should always be used (91%). Most women (80%) at least somewhat agreed they have enough knowledge about preeclampsia and its complications. Over 90% of women agreed a test to predict complications of preeclampsia would be useful to them. Most women reported a rule out test would be useful to them because it would help them worry less (68%), reduce hospitalizations (32%) and reduce interventions (17%). CONCLUSION: There was majority support for novel methods such as biomarker testing among this cohort. Most patients reported the test would decrease worry associated with preeclampsia development and complications.

Elimination of racial disparities in postpartum hypertension follow-up after incorporation of telehealth into a quality bundle.

BACKGROUND: Black people have a disproportionately higher risk of hypertensive disorders of pregnancy and postpartum complications than White people but historically lower rates of postpartum follow-up. Few studies have investigated telehealth in the postpartum population. OBJECTIVE: This study aimed to investigate whether rapid switch to telehealth with audio-based visits during the COVID-19 pandemic decreased racial disparities in postpartum hypertension follow-up adherence. STUDY DESIGN: This retrospective cohort study included all the patients with hypertensive disorders of pregnancy who delivered between December 2019 and June 2020 at an urban tertiary care center. A preexisting postpartum hypertension quality improvement initiative was in place at this institution. Follow-up adherence within 6 weeks postpartum and at the 6-week visit were compared before February 15, 2020 (pretelehealth period) and following March 14, 2020 (post-telehealth period), with a 1-month implementation or washout period. The blood pressures at these visits were compared between time periods as a secondary outcome. RESULTS: A total of 473 patients were included in this analysis, of whom 76.3% were non-Hispanic Black. There were 215 and 258 patients in the pre- and post-telehealth cohorts, respectively. Among those who attended follow-up, the proportion of visits done over telehealth went from 0% pretelehealth to 98.0% post-telehealth. The proportion of postpartum hypertension follow-up attendance changed from 48.5% to 76.3% among non-Hispanic Black people (P<.0001) and from 73.1% to 76.7% among non-Hispanic White people (P=.76), leaving only a 0.4% racial gap (P=.97). This resulted in an elimination of the racial disparities in the post-telehealth period. CONCLUSION: Transition to telehealth with audio-based visits at the onset of the COVID-19 pandemic improved attendance at postpartum hypertension visits among non-Hispanic Black people. This, therefore, led to significant decreases in the racial disparities in follow-up rates at our institution in the setting of an existing quality improvement initiative. Further research should focus on the intentional use of telehealth in improving maternal outcomes, especially among the non-Hispanic Black people.

Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: Recent Advances in Hypertension.

Patients with a history of hypertensive disorders of pregnancy (HDP) suffer higher rates of long-term cardiovascular events including heart failure, coronary artery disease, and stroke. Cardiovascular changes during pregnancy can act as a natural stress test, subsequently unmasking latent cardiovascular disease in the form of HDP. Because HDP now affect 10% of pregnancies in the United States, the American Heart Association has called for physicians who provide peripartum care to promote early identification and cardiovascular risk reduction. In this review, we discuss the epidemiology, pathophysiology, and outcomes of HDP-associated cardiovascular disease. In addition, we propose a multi-pronged approach to support cardiovascular risk reduction for women with a history of HDP. Additional research is warranted to define appropriate blood pressure targets in the postpartum period, optimize the use of pregnancy history in risk stratification tools, and clarify the effectiveness of preventive interventions. The highest rates of HDP are in populations with poor access to resources and quality health care, making it a major risk for inequity of care. Interventions to decrease long-term cardiovascular disease risk in women following HDP must also target disparity reduction.

Long-Term Postpartum Cardiac Function and Its Association With Preeclampsia.

Background Preeclampsia is a prominent risk factor for long-term development of cardiovascular disease. Although existing studies report a strong correlation between preeclampsia and heart failure, the underlying mechanisms are poorly understood. One possibility is the glycoprotein growth factor activin A. During pregnancy, elevated activin A levels are associated with impaired cardiac global longitudinal strain at 1 year, but whether these changes persist beyond 1 year is not known. We hypothesized that activin A levels would remain increased more than 1 year after a preeclamptic pregnancy and correlate with impaired cardiac function. Methods and Results To test our hypothesis, we performed echocardiograms and measured activin A levels in women approximately 10 years after an uncomplicated pregnancy (n=25) or a pregnancy complicated by preeclampsia (n=21). Compared with women with a previously normal pregnancy, women with preeclampsia had worse global longitudinal strain (-18.3% versus -21.3%, P=0.001), left ventricular posterior wall thickness (0.91 mm versus 0.80 mm, P=0.003), and interventricular septal thickness (0.96 mm versus 0.81 mm, P=0.0002). Women with preeclampsia also had higher levels of activin A (0.52 versus 0.37 ng/mL, P=0.02) and activin/follistatin-like 3 ratio (0.03 versus 0.02, P=0.04). In a multivariable model, the relationship between activin A levels and worsening global longitudinal strain persisted after adjusting for age at enrollment, mean arterial pressure, race, and body mass index (P=0.003). Conclusions Our findings suggest that both activin A levels and global longitudinal strain are elevated 10 years after a pregnancy complicated by preeclampsia. Future studies are needed to better understand the relationship between preeclampsia, activin A, and long-term cardiac function.

Real life outpatient biomarker use in management of hypertensive pregnancies in third trimester in a low resource SeTting: ROBUST study.

OBJECTIVES: The utility of angiogenic biomarkers in a low resource outpatient setting is not well known. This study evaluates the clinical utility of angiogenic biomarkers, soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF) among patients at risk for preeclampsia in a low resource outpatient setting. STUDY DESIGN: This was a prospective pilot study among high risk third trimester outpatients conducted in Bengaluru, India. Serum sFlt1/PlGF was measured between 28 and 37 weeks. Patients with high risk ratio were managed with close observation, intermediate risk had serum redrawn in one week, and those with low risk ratio received routine care. Delivery decisions were made based on local protocols. MAIN OUTCOME MEASURES: Maternal complication rate, development of preeclampsia with severe features, and latency to delivery was examined by sFlt1/PlGF ratio. RESULTS: The study included 50 patients. Compared to women with a low risk ratio, women with a high-risk ratio were more likely to have preeclampsia with severe features (90.91% vs 8.00%, p < 0.0001), a higher composite maternal complication rate (18.18% vs 0%, p = 0.04) and deliver at earlier gestational ages (32.57 [30.43, 34.71] vs 37.43 [36.86, 38.14] weeks, p = 0.0001). CONCLUSION: Angiogenic factors may have utility in the low resource outpatient setting for women with a hypertensive disease. Low sFlt1/PlGF levels were associated with a longer latency to delivery and no maternal complications. This study confirms the broad clinical utility of biomarkers in the real world.

Angiogenic factor abnormalities and risk of peripartum complications and prematurity among urban predominantly obese parturients with chronic hypertension.

OBJECTIVE: To compare characteristics and outcomes of women with chronic hypertension (cHTN) between those with normal and abnormal plasma angiogenic profiles. STUDY DESIGN: This secondary analysis explored associations between angiogenic markers soluble fms-like tyrosine kinase-1 (sFlt1) and placental growth factor (PlGF) drawn prior to delivery among women with history of cHTN who were enrolled between 22 and 41 weeks. Patients were divided into two groups based on sFlt1/PlGF ratio, namely low sFlt1/PlGF (<85) and high sFlt1/PlGF (≥85) ratio. RESULTS: Of the 115 patients, 76% were African American. Compared to women with low sFlt1/PlGF (n = 78), patients with high sFlt1/PlGF (n = 37) had higher median antenatal blood pressures (systolic mmHg 179 vs 155; diastolic 106 vs 91), lower gestational age at delivery (34.7 vs 38.2 weeks), lower birthweight (1940 vs 3103 g), and a higher prevalence of preterm delivery <34 (40.5% vs 7.7%) and <37 weeks (64.9% vs 20.5%), all p < 0.001. Importantly, more women with high sFlt1/PlGF had a diagnosis of superimposed preeclampsia (62.2% vs 26.9%, p = 0.003), preeclampsia with severe features (59.5% vs 20.5%, p < 0.0001), maternal adverse outcomes (24.3% vs 3.9%, p = 0.002), neonatal intensive care unit admissions (71.9% vs 40.8%; p = 0.003), severe postpartum hypertension (67.6% vs 38.5%, p = 0.01) and longer hospital stays (median 6.0 vs 4.5 days, p = 0.003). DISCUSSION: In contrast to patients with a low ratio, high sFlt1/PlGF is characterized by an increased risk of maternal adverse outcomes and prematurity. Incorporation of angiogenic biomarkers while managing cHTN may improve accuracy of early identification of adverse outcomes to improve outcomes.

Effect of blood pressure control in early pregnancy and clinical outcomes in African American women with chronic hypertension.

OBJECTIVE: Chronic hypertension (cHTN) affects 3-5% of all pregnancies and is twice as prevalent in African American (AA) women. AA women develop more severe HTN at an earlier onset and have higher rates of adverse pregnancy outcomes. Blood pressure control during pregnancy is controversial. STUDY DESIGN: This retrospective cohort included AA women with cHTN and singleton pregnancies delivering between January 2013 and December 2016. Patients were classified as not receiving antihypertensives in the first 20 weeks (Group A), on antihypertensives in the first 20 weeks but with an average BP <140/90 during pregnancy (Group B) and on antihypertensives in the first 20 weeks but with average BP during pregnancy ≥140/90 (Group C). Adverse outcomes including severe HTN and preterm delivery <35 weeks was compared between groups. RESULTS: Of the 198 patients included, 68 received at least one AHT before 20 weeks including 45 patients with average BP <140/90 and 23 with average BP ≥140/90 during pregnancy. The incidence of superimposed PE and preterm birth was significantly higher among women with elevated BPs on AHT (39.1% vs 8.9% vs 17.7%, p = 0.01; preterm birth 52.2%, 8.9% and 9.2%, p < 0.001 for Groups C, B and A, respectively). A significantly higher proportion of adverse neonatal outcomes were observed in Group C (78.3%) as opposed to those in Group B (53.3%) or Group A (50.0%; p = 0.04). CONCLUSIONS: Among AA women with cHTN, use of antihypertensives prior to 20 weeks and lower antenatal BP was associated with a decreased risk of adverse maternal and neonatal outcomes.