Caring for Patients with Gestational Hypertensive Disorders: Essential Takeaways.

Hypertensive disorders in pregnancy (HDP) are a group of conditions-including chronic hypertension, gestational hypertension, preeclampsia with and without end-organ damage, and acute complications, which include HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome and eclampsia-that could lead to severely adverse outcomes for both mother and fetus. The incidence of HDP has increased, affecting one out of seven delivery hospitalizations. Physicians should be aware of HDP for early identification and proper treatment to improve patient outcomes.

Hypertensive Disorders of Pregnancy.

According to the American College of Obstetricians and Gynecologists (ACOG), women who have a systolic blood pressure ≥ 140 mm Hg and/or a diastolic pressure ≥ 90 mm Hg before pregnancy or before 20 weeks of gestation have chronic hypertension. Up to 1.5% of women in their childbearing years have a diagnosis of chronic hypertension, and 16% of pregnant women develop hypertension during their pregnancy. Physiological cardiovascular changes from pregnancy may mask or exacerbate hypertensive diseases during gestation, which is why prepregnancy counseling is emphasized for all patients to optimize comorbidities and establish a patient's baseline blood pressure. This review provides an overview of the diagnoses and treatments of hypertensive diseases that can occur in pregnancy, including definitions of key terms and types of hypertension as well as ACOG recommendations.

Knowledge and care regarding long-term cardiovascular risk after hypertensive disorders of pregnancy and gestational diabetes.

BACKGROUND: Adverse pregnancy outcomes (APO), such as preeclampsia (PE) and gestational diabetes (GDM) are substantial risk factors for cardiovascular disease (CVD) later in life. Identifying these high-risk female individuals during pregnancy offers the possibility of preventing long-term CVD and chronic kidney disease via a structured therapeutic and surveillance plan. We aimed to evaluate the current practice of postpartum care in women after APO and the impact on the women's awareness about their future risk for CVD. METHODS: Women diagnosed with PE and GDM at the University Hospital of St. Poelten/Lilienfeld between 2015-2020 were identified and participated in a structured telephone interview about postpartum medical care and knowledge about the impact of APOs on long-term cardiovascular health. RESULTS: Of 161 out of the 750 women contacted, 29% (n = 46) were diagnosed with PE and 71% (n = 115) with GDM. One third of all women and up to 44% of women diagnosed with PE, were unaware that APOs are related to CVD. Women diagnosed with PE were less likely to receive postpartum care information than those with GDM (30.4% vs. 49.6%, p = 0.027), and only one third of all women after APOs were counselled by a physician or healthcare professional. Of the women 50% received recommendations regarding lifestyle changes after delivery; significantly more women with GDM than women with PE (54% vs. 37%, p = 0.05). Only 14% had at least one long-term follow-up. CONCLUSION: This study identified a significant deficit of structured postpartum care and a lack of awareness among women after APO and their healthcare providers about the increased risk of long-term CVD.

The contribution of hypertensive disorders of pregnancy to late preterm and term admissions to neonatal units in the UK 2012-2020 and opportunities to avoid admission: A population-based study using the National Neonatal Research Database.

OBJECTIVE: To quantify maternal hypertensive disorder of pregnancy (HDP) prevalence in late preterm and term infants admitted to neonatal units (NNU) and assess opportunities to avoid admissions. DESIGN: A retrospective population-based study using the National Neonatal Research Database. SETTING: England and Wales. POPULATION: Infants born ≥34 weeks' gestation admitted to NNU between 2012 and 2020. METHODS: Outcomes in HDP infants are compared with non-HDP infants using regression models. MAIN OUTCOME MEASURES: Hypertensive disorder of pregnancy, primary reason for admission, clinical diagnoses and resource use. RESULTS: 16 059/136 220 (11.8%) of late preterm (34+0 to 36+6 weeks' gestation) and 14 885/284 646 (5.2%) of term (≥37 weeks' gestation) admitted infants were exposed to maternal HDP. The most common primary reasons for HDP infant admission were respiratory disease (28.3%), prematurity (22.7%) and hypoglycaemia (16.4%). HDP infants were more likely to be admitted with primary hypoglycaemia than were non-HDP infants (odds ratio [OR] 2.1, 95% confidence interval [CI] 2.0-2.2, P < 0.0001). 64.5% of HDP infants received i.v. dextrose. 35.7% received mechanical or non-invasive ventilation. 8260/30 944 (26.7%) of HDP infants received intervention for hypoglycaemia alone (i.v. dextrose) with no other major intervention (respiratory support, parenteral nutrition, central line, arterial line or blood transfusion). CONCLUSIONS: The burden of maternal HDP on late preterm and term admissions to NNU is high, with hypoglycaemia and respiratory disease being the main drivers for admission. Over one in four were admitted solely for management of hypoglycaemia. Further research should determine whether maternal antihypertensive agent choice or postnatal pathways may reduce NNU admission.

Quality of antenatal care and outcomes of Hypertensive Disorders in Pregnancy among antenatal attendees: A comparison of urban and periurban health facilities in Ghana.

Rural-urban-peri urban disparity assessments on health outcomes have been considered as critical determinants of health and health service outcomes. It is policy relevant in terms of the burden of disease and also provides focus on target interventions. This study aimed to assess the differences in the quality of Ante-natal Care (ANC) and the outcomes of Hypertensive Disorders in Pregnancy (HDPs) from selected health facilities in Ghana. This was a questionnaire-based cross-sectional study. Data on demographics, proportions of HDPs, quality of ANC and the outcomes of HDPs were collected. Logistic regression models were used to examine the association of the independent variables with the location of the health of facility. A total of 500 pregnant women were included in this study. There were 270 (54%) urban and 230 (46%) peri-urban dwellers. The proportion of HDPs varied with the location of the health facility. Women attending urban health facilities were more likely to be hypertensive (µ2 = 126.4; p<0.001), have chronic hypertension with superimposed pre-eclampsia (p< 0.001), have good quality ANC (µ2 = 41.28; p< 0.001), deliver full term (µ2 = 4.83; p = 0.028), and have excellent knowledge on HDPs (µ2 = 227.65; p< 0.001) compared to women receiving care in peri-urban health facilities. The method of delivery and outcome of birth did not statistically vary amongst the periurban and urban health facilities. There was an increase in the proportion in preterm in urban compared to periurban. The burden of HDPs was high in urban health facilities with high proportion of its mothers receiving quality ANC as well as having excellent knowledge on HDPs compared to mothers receiving care at the periurban health facilities. There is a need to target maternal care interventions to the periurban health facilities to improve obstetric health outcomes.

Effects of information-knowledge-attitude-practice health education combined with cluster-based care in patients with gestational hypertension.

To analyze the impact of information-knowledge-attitude-practice (IKAP) health education incorporated with cluster-based care on blood pressure control, pregnancy outcome and life quality in those who have gestational hypertension, and to provide methodological backing for the care of patients. A total of 80 patients with pregnancy-induced hypertension were selected as the research objects and randomly divided into control and experimental groups, with 40 cases in each group. The control group received routine cluster care, which included providing individual and group health information through the distribution of health education manuals to hypertensive patients during pregnancy and their families. The experimental group received additional IKAP health education, including data collection, health knowledge imparted, concept change and behavior generation process. Blood pressure control status was measured and recorded. Adverse pregnancy outcomes include placenta previa, cesarean section, hyperamniotic fluid, fetal distress, and postpartum hemorrhage. Postpartum quality of life conditions, including physical activity, emotional awareness, physical discomfort, mental health, sleep quality, postpartum anxiety or depression, and general health were evaluated. Age, prepregnancy BMI, and educational level did not significantly vary between the 2 groups(P > .05). In comparison to the control group, the experimental group demonstrated healthier behavior. Blood pressure and weight control during pregnancy were better than control group. The frequency of adverse pregnancy was inferior to control group. The number of adverse neonatal conditions was inferior to control group. The postpartum quality of life score was higher in the experimental group compared to the control group. The combination of IKAP health education and cluster based care has a better effect on blood pressure control compared to the sole use of cluster based care. This approach can reduce the likelihood of experiencing adverse pregnancy outcomes and help improve the quality of life for patients after delivery.

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.

BACKGROUND: Nigeria 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. METHODS: From 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. RESULTS: The 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. CONCLUSION: This 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.

The long-term risk of cardiovascular disease among women with a history of hypertensive disorders of pregnancy: a systematic review of clinical practice guidelines.

BACKGROUND: The lifelong risks of cardiovascular disease following preeclampsia and gestational hypertension are well-established. However, it is unclear whether this evidence has been translated into clinical practice guidelines. Thus, this review aimed to assess the quality and content of Australian clinical practice guidelines regarding the risk of cardiovascular disease following gestational hypertension and preeclampsia. METHODS: We conducted a systematic search of MEDLINE (Ovid), EMBASE (Ovid), and CINAHL databases, as well as hospital, obstetric society, and medical college websites. Publications were included if: they were a clinical practice guideline; were published in the previous ten years; and included recommendations for the management of future cardiovascular disease risk following hypertensive disorders of pregnancy. Quality assessment was performed using Appraisal of Guidelines for Research and Evaluation Instrument Version Two (AGREE-II) and AGREE Recommendations Excellence Instrument (AGREE-REX). RESULTS: Eighteen guidelines were identified, and of these, less than half (n = 8) included recommendations for managing future cardiovascular risk following hypertensive disorders of pregnancy. Across these eight, four main counselling recommendations were found regarding (1) risk of future cardiovascular disease; (2) risk factor screening; (3) lifestyle interventions; and (4) prenatal counselling for future pregnancies. The quality and content of these recommendations varied significantly, and the majority of guidelines (87.5%) were assessed as low to moderate quality. CONCLUSIONS: There are limited Australian clinical practice guidelines providing appropriate advice regarding future risk of cardiovascular disease following hypertensive disorders of pregnancy. The quality and content of these guidelines varied significantly. These findings highlight the need for improved translation from evidence-based research to enhance clinical care and guidance.

Hypertension in Women and Pregnancy.

Hypertension has been shown to have long-term cardiovascular effects if left untreated. Hypertension also has been shown to affect women during pregnancy, which can be detrimental not only to the patient but also to the fetus. Early identification and treatment are paramount to prevent adverse outcomes. This article details the epidemiology, clinical presentation, diagnosis, and treatment of essential hypertension in women, gestational hypertension, preeclampsia, and eclampsia.

Utility of Weekly Laboratory Monitoring in the Expectant Management of Hypertensive Disorders of Pregnancy.

Our retrospective cohort study evaluates the diagnostic yield of weekly laboratory surveillance in outpatient management of hypertensive disorders of pregnancy (HDP) based on patient clinical status at the time of laboratory testing. The study included 459 patients and 1,082 laboratory episodes: 356 (32.9%) episodes were performed in the setting of concerning clinical findings and 726 (67.1%) when the patient was asymptomatic. Overall, the diagnostic yield for abnormal laboratory values (n=11) was 1.0% (95% CI 0.4-1.6%) of all assessments performed and 2.4% (95% CI 1.0-3.8%) among all patients in the cohort. The prevalence of abnormal test results was higher in patients with clinical findings (2.8%, 95% CI 1.1-4.5%) compared with those who were asymptomatic (0.1%, 95% CI 0-0.2%) ( P <.01). Clinical findings suggestive of worsening disease had a 91% sensitivity (95% CI 59-100%) and a 99% (95% CI 99-100%) negative predictive value for abnormal laboratory values. Directed screening based on signs and symptoms, rather than universal weekly screening, may be a potential strategy to lower costs and reduce multiple blood draws for patients with HDP, because there is a low diagnostic yield for this practice.

Hypertensive Disorders in Pregnancy: Global Burden From 1990 to 2019, Current Research Hotspots and Emerging Trends.

Hypertensive disorders in pregnancy (HDP) constitute a worldwide health problem for pregnant women and their infants. This study provided HDP burden over 1990 to 2019 by region and age distribution, and predicted changes in related values for the next 25 years. We then conducted an econometric analysis of the author distribution, collaborative networks, keyword burst clustering, and spatio-temporal analysis of HDP-related publications from 2012 to 2022 to access current scientific developments and hotspots. The number of pregnant women with HDP has been increasing over the past 30 years, with regional and age-stratified differences in the burden of disease. Additionally, projections suggest an increase of deaths due to maternal HDP among adolescents younger than 20 years. Current research is mostly centered on pre-eclampsia, with hot keywords including trophoblast, immune tolerance, frozen-thawed embryo transfer, aspirin, gestational diabetes association, and biomarkers. Researches on the pathological mechanism, classification, and subtypes of HDP need to be further advanced.

Timing of outpatient postpartum care utilization among women with chronic hypertension and hypertensive disorders of pregnancy.

BACKGROUND: The postpartum period represents an opportunity to assess the cardiovascular health of women who experience chronic hypertension or hypertensive disorders of pregnancy. OBJECTIVE: This study aimed to determine whether women with chronic hypertension or hypertensive disorders of pregnancy access outpatient postpartum care more quickly compared to women with no hypertension. STUDY DESIGN: We used data from the Merative MarketScan Commercial Claims and Encounters Database. We included 275,937 commercially insured women aged 12 to 55 years who had a live birth or stillbirth delivery hospitalization between 2017 and 2018 and continuous insurance enrollment from 3 months before the estimated start of pregnancy to 6 months after delivery discharge. Using the International Classification of Diseases Tenth Revision Clinical Modification codes, we identified hypertensive disorders of pregnancy from inpatient or outpatient claims from 20 weeks gestation through delivery hospitalization and identified chronic hypertension from inpatient or outpatient claims from the beginning of the continuous enrollment period through delivery hospitalization. Distributions of time-to-event survival curves (time-to-first outpatient postpartum visit with a women's health provider, primary care provider, or cardiology provider) were compared between the hypertension types using Kaplan-Meier estimators and log rank tests. We used Cox proportional hazards models to estimate adjusted hazard ratios and 95% confidence intervals. Time points of interest (3, 6, and 12 weeks) were evaluated per clinical postpartum care guidelines. RESULTS: Among commercially insured women, the prevalences of hypertensive disorders of pregnancy, chronic hypertension, and no documented hypertension were 11.7%, 3.4%, and 84.8%, respectively. The proportions of women with a visit within 3 weeks of delivery discharge were 28.5%, 26.4%, and 16.0% for hypertensive disorders of pregnancy, chronic, and no documented hypertension, respectively; by 12 weeks, the proportions increased to 62.4%, 64.5%, and 54.2%, respectively. Kaplan-Meier analyses indicated significant differences in utilization by hypertension type and interaction between hypertension type, and time before and after 6 weeks. In adjusted Cox proportional hazards models, the utilization rate before 6 weeks among women with hypertensive disorders of pregnancy was 1.42 times the rate for women with no documented hypertension (adjusted hazard ratio, 1.42; 95% confidence interval, 1.39-1.45). Women with chronic hypertension also had higher utilization rates compared to women with no documented hypertension before 6 weeks (adjusted hazard ratio, 1.28; 95% confidence interval, 1.24-1.33). Only chronic hypertension was significantly associated with utilization compared to the no documented hypertension group after 6 weeks (adjusted hazard ratio, 1.09; 95% confidence interval, 1.03-1.14). CONCLUSION: In the 6 weeks following delivery discharge, women with hypertensive disorders of pregnancy and chronic hypertension attended outpatient postpartum care visits sooner than women with no documented hypertension. However, after 6 weeks this difference extended only to women with chronic hypertension. Overall, postpartum care utilization remained around 50% to 60% by 12 weeks in all groups. Addressing barriers to postpartum care attendance can ensure timely care for women at high risk for cardiovascular disease.

Electronic Reminder to Transition Care After Hypertensive Disorders of Pregnancy: A Randomized Controlled Trial.

OBJECTIVE: Scalable interventions are needed to improve preventive care for those with increased cardiovascular disease (CVD) risk identified during pregnancy. We hypothesized that an automated reminder message for clinicians (nudge) would increase counseling at the postpartum visit on patient transitions of care. METHODS: We conducted a single-center, randomized controlled trial including birthing people with a hypertensive disorder of pregnancy evaluating a nudge compared with usual care. The nudge, including counseling phrases and patient-specific information on hypertensive diagnosis, was sent to the obstetric clinician through the electronic medical record up to 7 days before the postpartum visit. The primary outcome was documentation of counseling on transitions of care to primary care or cardiology. Secondary outcomes were documentation of CVD risk, use of counseling phrases, and preventive care visit within 6 months. A sample size of 94 per group (n=188) was planned to compare the nudge intervention with usual care; given the anticipated loss to follow-up, the sample size was increased to 222. Intention-to-treat analyses were performed, with P <.05 considered significant. RESULTS: From February to June 2021, 392 patients were screened, and 222 were randomized and analyzed. Of these, 205 (92.3%) attended a postpartum visit. Groups were similar, but more women in the usual care group had diabetes (16.1% vs 6.7%, P =.03). After adjustment for diabetes, patients in the nudge group were more likely to have documented counseling on transitions of care (38.8% vs 26.2%, adjusted relative risk [aRR] 1.53, 95% CI 1.02-2.31), CVD risk (21.4% vs 8.4%, aRR 2.57, 95% CI 1.20-5.49), and use of aspirin in a future pregnancy (14.3% vs 1.9%, aRR 7.49, 95% CI 1.66-33.93). Counseling phrases were used more often in the nudge group (11.2% vs 0.9%, aRR 12.27, 95% CI 1.50-100.28). Preventive care visit attendance did not differ by group (22.1% vs 24.6%, aRR 0.91, 95% CI 0.57-1.47). CONCLUSION: A timely electronic reminder to obstetric clinicians improved counseling about transitions of care after hypertensive disorders of pregnancy but did not result in increased preventive care visit attendance. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT04660032.

The role of artificial intelligence in hypertensive disorders of pregnancy: towards personalized healthcare.

INTRODUCTION: Guidelines advise ongoing follow-up of patients after hypertensive disorders of pregnancy (HDP) to assess cardiovascular risk and manage future patient-specific pregnancy conditions. However, there are limited tools available to monitor patients, with those available tending to be simple risk assessments that lack personalization. A promising approach could be the emerging artificial intelligence (AI)-based techniques, developed from big patient datasets to provide personalized recommendations for preventive advice. AREAS COVERED: In this narrative review, we discuss the impact of integrating AI and big data analysis for personalized cardiovascular care, focusing on the management of HDP. EXPERT OPINION: The pathophysiological response of women to pregnancy varies, and deeper insight into each response can be gained through a deeper analysis of the medical history of pregnant women based on clinical records and imaging data. Further research is required to be able to implement AI for clinical cases using multi-modality and multi-organ assessment, and this could expand both knowledge on pregnancy-related disorders and personalized treatment planning.

Hypertensive Disorders of Pregnancy.

Hypertensive disorders in pregnancy are a leading cause of global maternal and fetal morbidity. The four hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and chronic hypertension with superimposed preeclampsia. A careful history, review of systems, physical examination, and laboratory analysis can help differentiate these disorders and quantify the severity of the disease, which holds important implications for disease management. This article reviews the different types of disorders of hypertension in pregnancy and how to diagnose and manage these patients, with special attention paid to any recent changes made to this management algorithm.