What is the clinical question being addressed?
What is the feasibility of a remote BP management program extending through the first year postpartum for individuals with persistent hypertension?
What is the main finding?
BP monitoring beyond 6 weeks postpartum is feasible for optimization of BP in a socioeconomically diverse cohort with persistent hypertension.
Hypertensive disorders of pregnancy (HDP) are associated with high rates of ongoing postpartum hypertension.1 Significant gaps in care can lead to suboptimally treated hypertension in the year after delivery.1 Remote blood pressure (BP) monitoring is a feasible method to manage HDP in the immediate 6-week postpartum period and may provide a unique opportunity for early cardiovascular risk factor management beyond the immediate postpartum period.2
Our institution has an established remote BP management program in the first 6 weeks postpartum.2 We have found that 50% of individuals with HDP have persistent hypertension at the end of the 6-week program and gaps in follow-up with a primary care provider (PCP) for longitudinal BP management, leading to a high burden of suboptimally treated hypertension. The objective of this study is to establish feasibility of a remote BP management program extending through the first year postpartum.
Eligible individuals have a HDP (chronic hypertension, preeclampsia, gestational hypertension). Maternal, obstetric, and sociodemographic data are obtained from the electronic medical record at the University of Pittsburgh Medical Center. Patients are initially enrolled into the immediate postpartum (6-week) remote BP monitoring program at the time of discharge from delivery hospitalization, emergency room visit, or postpartum readmission. A description of the immediate postpartum remote monitoring program has been previously published.2
We developed an extension of this remote monitoring program beginning at 6 weeks postpartum and continuing up to 1-year postpartum, for individuals with persistent hypertension. Persistent hypertension is defined as: continuing to require antihypertensive medications and/or BPs ≥130/80 mm Hg. Individuals with persistent hypertension are given the option to continue home monitoring through our extension program (opt-in) on day 21 of the program and again at the conclusion of the 6-week program. The extension program prompts BP reporting twice per week through the first year postpartum. Once goal BP (<140/90 mm Hg) is achieved with 8 consecutive BP measurements and participants are no longer on antihypertensive medications, patients can be “graduated” from the monitoring program. Otherwise, patients participate for 365 days, and PCP follow-up is ensured at graduation.
Among those with persistent hypertension eligible for the extended monitoring, we compare those who participated in extended monitoring with those who participated only in the immediate 6-week monitoring postpartum. We compare continuous variables using Student’s t-test and Wilcoxon-Mann-Whitney tests (Stata SE 18, StataCorp LP). We compare categorical variables using chi-square or Fisher’s exact. We consider P values <0.05 as statistically significant.
Of the 3,662 individuals with persistent hypertension, 1,318 (36%) participated in extended monitoring. Those in the extended monitoring program differed from those only monitored for 6 weeks by demographic and clinical factors related to HDP (Table 1).
Table 1.
Clinical Characteristics of Participants in Extended Monitoring Versus Nonparticipants in Extended Monitoring Among Those With Persistent Hypertension at 6 Weeks (N = 3,662)
| 6-Wk Remote Monitoring (n = 2,344) | Extended Remote Monitoring (n = 1,318) | P Value | |
|---|---|---|---|
| Maternal demographics | |||
| Maternal age (y) | 31.1 ± 5 | 32.6 ± 5.2 | <0.001 |
| Race | 0.020 | ||
| Caucasian | 1,840 (79) | 959 (73) | |
| Black | 612 (16) | 285 (22) | |
| Other (Asian, Hispanic, Native American) | 116 (5) | 74 (5) | |
| Insurance status | 0.001 | ||
| Commercial | 1,655 (72) | 848 (66) | |
| Public | 612 (26) | 403 (32) | |
| Self-pay/Other | 44 (2) | 28 (2) | |
| Prepregnancy BMI (kg/m2) | 30.1 (25-35) | 29.7 (25-35) | 0.411 |
| Gestational diabetes | 331 (14) | 207 (16) | 0.194 |
| Gestational age of delivery (wk) | 37.6 ± 3.7 | 37.4 ± 3.6 | 0.051 |
| Hypertension in pregnancy | |||
| Preeclampsia with severe features | 644 (27) | 343 (26) | 0.215 |
| Preeclampsia without severe features | 261 (11) | 199 (15) | 0.010 |
| Chronic hypertension | 384 (16) | 258 (20) | 0.003 |
| Gestational hypertension | 1,055 (45) | 518 (39) | <0.001 |
| Cohort characteristics | |||
| Discharged postpartum with medication | 568 (24) | 414 (31) | <0.001 |
| Initiated or titrated medications | 1,423 (60) | 1,011 (77) | <0.001 |
| PP hypertension clinic visits | 52 (2) | 254 (20) | <0.001 |
| PP ED visits before initial 6-wk program | 284 (12) | 205 (16) | 0.003 |
| PP hospitalizations before initial 6-wk program | 127 (5) | 118 (9) | <0.001 |
| Primary care visit within 18 mo postpartum | 906 (39) | 602 (46) | <0.001 |
| Number of wk in the program | 5.9 (5-6) | 23.0 (11-31) | <0.001 |
| Number of BP recorded | 25.1 (20-29) | 39.0 (25-53) | <0.001 |
| Highest systolic BP in initial 6-wk program, mm Hg | 145 ± 12 | 150 ± 15 | <0.001 |
| Highest diastolic BP in initial 6-wk program, mm Hg | 96 ± 8 | 98 ± 10 | <0.001 |
Values are mean ± SD, n (%), or median (IQR).
ED = emergency department; BMI = body mass index; BP = blood pressure; PP = postpartum.
Of those who participated in extended monitoring, BP was lower at the conclusion of the extended monitoring program compared with BP at 6 weeks after delivery (systolic BP 121 ± 8 mm Hg vs 125 ± 7 mm Hg; diastolic BP 79 ± 9 mm Hg vs 82 ± 6 mm Hg; both P < 0.001). Among the extended monitoring group, regardless of the type of HDP, a higher proportion achieved BP control at the end of monitoring compared with 6 weeks postpartum: BP <140/90 mm Hg (92% vs 71%; P < 0.001) and BP <130/80 mm Hg (55% vs 30%; P < 0.001).
Remote BP management in the year postpartum is feasible in a racially and socioeconomically diverse cohort of individuals with HDP. Extended participation was associated with higher rates of postpartum PCP visits and higher rates of BP control compared with 6 weeks after delivery.
Even in the context of our robust program,2 a minority of patients with persistent hypertension participated in extended monitoring and had a PCP visit, highlighting the importance of ongoing innovative approaches to engagement in care for this high-risk population. One limitation is that the postpartum BP management program is conducted at a single center, which may limit the generalizability of the findings to other settings. The financial sustainability of this program is possible through support from the hospital system and the extension of Medicaid coverage up to 1-year postpartum in Pennsylvania.
Our findings suggest that implementation of ongoing BP monitoring beyond the immediate 6 weeks postpartum in those with persistent hypertension after a HDP is feasible for optimization of BP and may contribute to minimizing future cardiovascular risk.
Footnotes
This work was supported by NIH/ORWHBuilding Interdisciplinary Research Careers in Women’s Health (BIRCWH) NIHK12HD043441, AHA CDA 941351, and The Magee Womens Hospital Medical Staff Grant. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
This study was approved by the University of Pittsburgh Institutional Review Board (STUDY21010100).
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
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