Postpartum Management of Hypertensive Disorders of Pregnancy in Six Large U.S. Hospital Systems: Descriptive Review and Identification of Clinical and Research Gaps

Abstract

Hypertensive disorders of pregnancy (HDPs) are a key contributor to maternal morbidity and mortality. Several gaps in knowledge remain regarding best practices in the postpartum management of HDPs. In this review, we describe postpartum HDPs management among six large academic U.S. hospital systems: Medical College of Wisconsin, University of Pittsburgh, University of Wisconsin–Madison, Northwestern University, University of Minnesota, and Boston Medical Center. We identified that all six health systems discharge patients with HDPs diagnosed with a blood pressure (BP) cuff and use the same two antihypertensive medications, nifedipine and labetalol, as first- and second-line treatment of HDPs. Northwestern University routinely adds oral furosemide for 5 days for patients with BP that exceeds 150/100 mm Hg. Most hospital systems administer magnesium sulfate routinely when readmission for HDPs occurs. In contrast, there was variation in BP threshold for antihypertensive treatment initiation, use of remote BP monitoring program, use of a transition clinic, delivery or lack of education on long-term cardiovascular disease risk, and BP management through the first 6 weeks postpartum and beyond. Based on the clinical review, we identified clinical gaps and formulated considerations for research priorities in the field of postpartum HDPs management.

Key Points

• Several gaps in knowledge remain regarding best practices in postpartum management of HDPs.

• There is a variation in the BP threshold for antihypertensive treatment initiation.

• Data are lacking on the reduction in severe maternal morbidity (SMM) and racial disparities in SMM with remote monitoring.

Keywords

hypertensive disorders of pregnancy - postpartum - remote monitoring - antihypertensive treatment

• References

• 1 Hutcheon JA, Lisonkova S, Joseph KS. Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol 2011; 25 (04) 391-403
• 2 American College of Obstetricians and Gynecologists. Gestational hypertension and preeclampsia: ACOG Practice Bulletin Summary, Number 222. Obstet Gynecol 2020; 135 (06) 1492-1495
• 3 GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388 (10053): 1775-1812
• 4 Clapp MA, Little SE, Zheng J, Robinson JN. A multi-state analysis of postpartum readmissions in the United States. Am J Obstet Gynecol 2016; 215 (01) 113.e1-113.e10
• 5 Mogos MF, Salemi JL, Spooner KK, McFarlin BL, Salihu HH. Hypertensive disorders of pregnancy and postpartum readmission in the United States: national surveillance of the revolving door. J Hypertens 2018; 36 (03) 608-618
• 6 Too G, Wen T, Boehme AK. et al. Timing and risk factors of postpartum stroke. Obstet Gynecol 2018; 131: 70-78
• 7 Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011-2013. Obstet Gynecol 2017; 130 (02) 366-373
• 8 Briller J, Koch AR, Geller SE. Illinois Department of Public Health Maternal Mortality Review Committee Working Group. Maternal Cardiovascular Mortality in Illinois, 2002-2011. Obstet Gynecol 2017; 129 (05) 819-826
• 9 MacDorman MF, Thoma M, Declcerq E, Howell EA. Racial and ethnic disparities in maternal mortality in the United States using enhanced vital records, 2016‒2017. Am J Public Health 2021; 111 (09) 1673-1681
• 10 Hirshberg A, Downes K, Srinivas S. Comparing standard office-based follow-up with text-based remote monitoring in the management of postpartum hypertension: a randomised clinical trial. BMJ Qual Saf 2018; 27 (11) 871-877
• 11 American College of Obstetricians and Gynecologists.. ACOG Committee Opinion No. 736: Optimizing postpartum care. Obstet Gynecol 2018; 131 (05) e140-e150
• 12 Lopes Perdigao J, Hirshberg A, Koelper N, Srinivas SK, Sammel MD, Levine LD. Postpartum blood pressure trends are impacted by race and BMI. Pregnancy Hypertens 2020; 20: 14-18
• 13 Lopes Perdigao J, Lewey J, Hirshberg A. et al. Furosemide for accelerated recovery of blood pressure postpartum in women with a hypertensive disorder of pregnancy. Hypertension 2021; 77 (05) 1517-1524
• 14 Hauspurg A, Lemon LS, Quinn BA. et al. A postpartum remote hypertension monitoring protocol implemented at the hospital level. Obstet Gynecol 2019; 134 (04) 685-691
• 15 Hoppe KK, Thomas N, Zernick M. et al. Telehealth with remote blood pressure monitoring compared with standard care for postpartum hypertension. Am J Obstet Gynecol 2020; 223 (04) 585-588
• 16 Hirshberg A, Zhu Y, Smith-McLallen A, Srinivas SK. Association of a remote blood pressure monitoring program with postpartum adverse outcomes. Obstet Gynecol 2023; 141 (06) 1163-1170
• 17 Steele DW, Adam GP, Saldanha IJ. et al. Postpartum home blood pressure monitoring: a systematic review. Obstet Gynecol 2023; 142 (02) 285-295
• 18 Mei JY, Hauspurg A, Corry-Saavedra K, Nguyen TA, Murphy A, Miller ES. Remote blood pressure management for postpartum hypertension: a cost-effectiveness analysis. Am J Obstet Gynecol MFM 2024; 6 (09) 101442
• 19 Mukhtarova N, Alagoz O, Chen YH, Hoppe K. Evaluation of different blood pressure assessment strategies and cutoff values to predict postpartum hypertension-related readmissions: a retrospective cohort study. Am J Obstet Gynecol MFM 2021; 3 (01) 100252
• 20 Hoppe KK, Williams M, Thomas N. et al. Telehealth with remote blood pressure monitoring for postpartum hypertension: a prospective single-cohort feasibility study. Pregnancy Hypertens 2019; 15: 171-176
• 21 Palatnik A, Mukhtarova N, Hetzel SJ, Hoppe KK. Blood pressure changes in gestational hypertension, preeclampsia, and chronic hypertension from preconception to 42-day postpartum. Pregnancy Hypertens 2023; 31: 25-31
• 22 Thomas NA, Drewry A, Racine Passmore S, Assad N, Hoppe KK. Patient perceptions, opinions and satisfaction of telehealth with remote blood pressure monitoring postpartum. BMC Pregnancy Childbirth 2021; 21 (01) 153
• 23 Niu B, Mukhtarova N, Alagoz O, Hoppe K. Cost-effectiveness of telehealth with remote patient monitoring for postpartum hypertension. J Matern Fetal Neonatal Med 2022; 35 (25) 7555-7561
• 24 Safri AA, Kopcza BT, Kaplon SC. et al. Implementation of an interprofessional model for the management of postpartum hypertension. Am J Health Syst Pharm 2024; zxae203
• 25 Cairns AE, Pealing L, Duffy JMN. et al. Postpartum management of hypertensive disorders of pregnancy: a systematic review. BMJ Open 2017; 7 (11) e018696
• 26 Cairns AE, Tucker KL, Leeson P, Mackillop L, McManus RJ. Survey of healthcare professionals regarding adjustment of antihypertensive medication(s) in the postnatal period in women with hypertensive disorders of pregnancy. Pregnancy Hypertens 2016; 6 (04) 256-258
• 27 Aderibigbe OA, Hackney DN, Ranzini AC, Lappen JR. Tight vs liberal control of mild postpartum hypertension: a randomized controlled trial. Am J Obstet Gynecol MFM 2023; 5 (02) 100818
• 28 Beardmore KS, Morris JM, Gallery EDM. Excretion of antihypertensive medication into human breast milk: a systematic review. Hypertens Pregnancy 2002; 21 (01) 85-95
• 29 Ormesher L, Higson S, Luckie M. et al. Postnatal Enalapril to Improve Cardiovascular Function Following Preterm Preeclampsia (PICk-UP): a randomized double-blind placebo-controlled feasibility trial. Hypertension 2020; 76 (06) 1828-1837
• 30 Redman CW, Kelly JG, Cooper WD. The excretion of enalapril and enalaprilat in human breast milk. Eur J Clin Pharmacol 1990; 38 (01) 99
• 31 Do SC, Leonard SA, Kan P. et al. Postpartum readmission for hypertension after discharge on labetalol or nifedipine. Obstet Gynecol 2022; 140 (04) 591-598
• 32 Viteri OA, Alrais MA, Pedroza C. et al. Torsemide for prevention of persistent postpartum hypertension in women with preeclampsia: a randomized controlled trial. Obstet Gynecol 2018; 132 (05) 1185-1191
• 33 Altman D, Carroli G, Duley L. et al; Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002; 359 (9321) 1877-1890
• 34 Cagino K, Prabhu M, Sibai B. Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum. Am J Obstet Gynecol 2023; 229 (06) 641-646
• 35 Bellamy L, Casas JPP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ 2007; 335 (7627) 974
• 36 McDonald SD, Malinowski A, Zhou Q, Yusuf S, Devereaux PJ. Cardiovascular sequelae of preeclampsia/eclampsia: a systematic review and meta-analyses. Am Heart J 2008; 156 (05) 918-930
• 37 Wu P, Haththotuwa R, Kwok CS. et al. Preeclampsia and future cardiovascular health. Circ Cardiovasc Qual Outcomes 2017; 10 (02) e003497
• 38 Benschop L, Duvekot JJ, Versmissen J, van Broekhoven V, Steegers EAP, Roeters van Lennep JE. Blood pressure profile 1 year after severe preeclampsia. Hypertension 2018; 71 (03) 491-498
• 39 Smith GN, Pudwell J, Saade GR. Impact of the New American Hypertension Guidelines on the prevalence of postpartum hypertension. Am J Perinatol 2019; 36 (04) 440-442
• 40 Parikh NI, Gonzalez JM, Anderson CAM. et al; American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; and the Stroke Council. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart Association. Circulation 2021; 143 (18) e902-e916
• 41 Cameron NA, Yee LM, Dolan BM, O'Brien MJ, Greenland P, Khan SS. Trends in cardiovascular health counseling among postpartum individuals. JAMA 2023; 330 (04) 359-367
• 42 Celi AC, Seely EW, Wang P, Thomas AM, Wilkins-Haug LE. Caring for women after hypertensive pregnancies and beyond: implementation and integration of a postpartum transition clinic. Matern Child Health J 2019; 23 (11) 1459-1466
• 43 Montero A, Sparks G, Kirzinger A, Valdes I, Published LH. KFF Health Tracking Poll July 2023: The Public's Views Of New Prescription Weight Loss Drugs and Prescription Drug Costs. KFF. Published August 4, 2023. Accessed January 8, 2024 at: https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-july-2023-the-publics-views-of-new-prescription-weight-loss-drugs-and-prescription-drug-costs/
• 44 Hefner JL, Hogan TH, Opoku-Agyeman W, Menachemi N. Defining safety net hospitals in the health services research literature: a systematic review and critical appraisal. BMC Health Serv Res 2021; 21 (01) 278
• 45 McKinley LP, Wen T, Gyamfi-Bannerman C. et al. Hospital safety-net burden and risk for readmissions and severe maternal morbidity. Am J Perinatol 2021; 38 (S 01): e359-e366
• 46 Reid LD, Weiss AJ, Fingar KR. Contributors to disparities in postpartum readmission rates between safety-net and non-safety-net hospitals: a decomposition analysis. J Hosp Med 2022; 17 (02) 77-87
• 47 Erickson EN, Carlson NS. Maternal morbidity predicted by an intersectional social determinants of health phenotype: a secondary analysis of the NuMoM2b dataset. Reprod Sci 2022; 29 (07) 2013-2029
• 48 Ditosto JD, Roytman MV, Dolan BM, Khan SS, Niznik CM, Yee LM. Improving postpartum and long-term health after an adverse pregnancy outcome: examining interventions from a health equity perspective. Clin Obstet Gynecol 2023; 66 (01) 132-149