Incorporating Maternal Blood Pressure Screening Into Routine Newborn Clinic Visits

Background

Hypertensive disorders of pregnancy (HDP), including chronic hypertension, gestational hypertension, pre-eclampsia, and postpartum hypertension, are key contributors to the increasing maternal mortality rate in the United States.^1,2 Among HDP, postpartum hypertension has a high risk of maternal morbidity and mortality and often goes unrecognized due to fewer health care interactions in the postpartum period.³ Despite low postpartum follow-up rates with obstetric providers, there is high adherence to newborn visits with pediatricians.^3–5 Currently, pediatricians screen for postpartum depression during newborn visits, supported by the American Academy of Pediatrics. There have also been initiatives to utilize pediatric settings to screen for maternal tobacco and contraception use, other factors impacting newborn health.⁶ Despite this precedent for maternal screening, there are limited data about additional postpartum maternal care at newborn visits.

Given increasing maternal mortality and morbidity, even physicians who do not typically provide direct care for postpartum patients have a responsibility to optimize maternal health.⁷ Newborn visits present an underutilized opportunity to screen recently pregnant individuals for postpartum complications. This study sought to assess the feasibility of implementing a maternal blood pressure (BP) screening program during newborn clinic visits.

Innovation and Context

We implemented a maternal BP screening program in a large, urban, academic pediatric primary care center through collaboration with pediatricians and maternal subspecialists in cardiology and maternal fetal medicine. The pediatric primary care center is located 0.2 miles from the obstetrics hospital, where 93% of the screened postpartum patients in this study were delivered. The project was approved by the University of Pittsburgh Medical Center Quality Improvement Review Committee and reviewed with exempt status by the institutional review board (STUDY 21040187).

This initiative involved screening postpartum individuals for vital signs and cardiovascular symptoms, adapted from the California Cardiovascular Toolkit.⁸ Seated BP was obtained using a validated automatic BP cuff. Elevated BP was defined as a systolic BP of ≥140 mm Hg or diastolic BP of ≥90 mm Hg. Postpartum was loosely defined as the first month based on the structure of our newborn-only resident clinic. Postpartum individuals were approached for voluntary screening after being roomed but before being seen by a provider. Screening was performed by residents and medical students.

Our vital sign measurement and response algorithm are shown in Figure. When a postpartum individual had abnormal vital signs or ≥2 cardiovascular symptoms, an on-call maternal fetal medicine or cardiology physician was contacted by the pediatrician via a secure internal messaging system. The on-call subspecialist provided guidance on management, factoring in symptoms, BP, and the presence of known HDP diagnosis. Responses included enrolling in an established remote BP monitoring program,⁹ facilitating short interval follow-up, or referral to the emergency department. The pediatrics team completed their role once the subspecialty team was notified.

Figure.

Screening algorithm and symptom questionnaire. BP indicates blood pressure; DBP, diastolic blood pressure; ED, emergency department; HDP, hypertensive disorder of pregnancy; HR, heart rate; OB/GYN, Obstetrics and Gynecology; and SBP, systolic blood pressure.

Results

We screened 72 postpartum individuals at a median of 9 (interquartile range 5, 15) days postpartum. Individuals were screened based on when staff was available to perform the screening. Most were publicly insured (78%) and self-identified as Black (69%). The mean systolic BP was 130 ± 19 mm Hg, and the mean diastolic BP was 86 ± 12 mm Hg. Of individuals screened in the clinic, 31 (43%) had an elevated BP, 13 (42%) of whom did not have a known HDP. The majority of those with known HDP (95%) had an elevated BP (≥140/90 mm Hg). Five individuals (7%) had severely elevated BP (≥160/110 mm Hg). Of those without known HDP, 4 were diagnosed with postpartum preeclampsia and 2 with postpartum hypertension.

Sixteen individuals (22%) with known HDP were enrolled in remote BP monitoring prior to their newborn appointment. Five individuals were newly enrolled in remote BP monitoring due to elevated BPs in the clinic. Of the individuals enrolled due to elevated BPs in the clinic, 3 went on to start antihypertensives. During the postpartum period, 8 individuals were started on anti-hypertensives or had medication uptitration through remote monitoring. In our screened population, 56% (n = 40) attended a postpartum obstetrics appointment within 12 weeks. Of the 13 individuals with elevated BP in the clinic, 7 attended a postpartum obstetrics appointment.

Discussion and Next Steps

Maternal BP screening in a newborn clinic provides an innovative safety net for recently pregnant individuals. In this study, we demonstrated that it is feasible to measure maternal BP in a pediatric clinic. Those with abnormal vitals were able to be appropriately triaged and managed through a multidisciplinary team. Given the number of interactions pediatricians have with mothers during the newborn period, pediatricians should be viewed as front-line providers for maternal postpartum care.

The American College of Obstetrics and Gynecology recommends a BP check within 10 days postpartum for individuals with HDP.¹⁰ However, the majority of individuals with known HDP do not attend these visits.¹¹ Remote BP monitoring has allowed for higher rates of BP screening; however, it is not universally available. Despite our relatively small sample size, a high proportion of postpartum individuals had elevated BP, those both with and without known HDP.

This project demonstrated many strengths, including serving a racially and socioeconomically diverse population, with a high burden of elevated BPs, at higher risk for maternal mortality and morbidity. There were also key engaged stakeholders, including pediatricians and maternal subspecialists, who ensured the success of this initiative. Educational sessions and identifying champions within the pediatrics clinic were essential for the success of this program. A multidisciplinary approach to maternal care offers an innovative way to address postpartum care gaps. A systematic review of postpartum care demonstrated varied rates of attendance at in-person postpartum obstetrics visits, ranging from 24.9% to 96.5%, with a mean of 72.1% while the American College of Gynecology estimates 60% attendance at a postpartum obstetric visit.^10,12

Despite our success, there were challenges to implementation. Our program was launched within a resident academic clinic with frequently rotating providers, which made full integration difficult. We are working towards a system where maternal vital signs would be assessed by a medical assistant, which would provide greater consistency and sustainability with the program. Additionally, there were multiple stakeholders with varying levels of comfort with triaging hypertension and concerns about potential legal liability. To address these concerns, we held multiple educational sessions with our team and were able to shift the care after screening to the obstetric team by enrolling postpartum individuals with moderately abnormal vitals into a structured remote BP monitoring program at our institution.⁹ Our program was additionally limited by the existing electronic medical record’s ability to link infant and maternal charts, as vital signs were not easily documented within the maternal chart. We are developing spaces within the electronic health record that would further facilitate communication of abnormal vitals with all care providers. Finally, we do not have estimates of the proportion of postpartum individuals who declined screening or declined further management after screening.

This collaborative initiative was able to safely identify postpartum individuals with elevated BPs and ensure that they receive appropriate and timely care. Pediatricians can utilize the continuity of care provided to mother-baby dyads in the immediate newborn period to positively impact maternal health as front-line providers. By providing simultaneous newborn and maternal care, pediatricians can play a key role in addressing the maternal health crisis in the United States.

What’s New.

This study demonstrates the feasibility of a maternal blood pressure screening program within a pediatric newborn clinic. Through the screening program, we identified a significant burden of elevated blood pressures among racially and socioeconomically diverse postpartum individuals.