Postpartum blood pressure monitoring and management: Critical findings from an expert convening

Abstract

Hypertensive disorders of pregnancy (HDP) are significant contributors to maternal morbidity and mortality, impacting an estimated 15.9% of delivery hospitalizations in the United States. More than 50% of hypertension‐related deaths occur postpartum, and it is estimated that 80% of maternal mortality cases are preventable. Given this, the American Medical Association hosted a convening of experts to discuss and identify areas of consensus on postpartum blood pressure (BP) monitoring and management clinical practices, including the use of self‐measured blood pressure (SMBP) and remote patient monitoring (RPM). Key recommendations include initiating antihypertensive therapy for BP ≥140/90 mmHg postdelivery, maintaining inpatient monitoring for at least 12 h after medication adjustment, providing all HDP patients with home BP devices and education at discharge, post‐discharge BP monitoring should be a minimum of once daily for at least 2 weeks postpartum, treatment protocols are recommended prior to implementation of home BP monitoring, and a coordinated transfer of care should be facilitated to a primary care provider for all patients with an HDP. While SMBP or RPM shows promise for improving outcomes, evidence for guidelines remains limited. The authors strongly recommend and support the need for further research to establish evidence for guidelines to support broad‐scale improvement in postpartum BP monitoring and management.

1. INTRODUCTION

Maternal mortality in the United States is a crisis, with mortality rates higher than those in other high‐income nations and considerable racial and ethnic inequities. Hypertensive disorders of pregnancy (HDP) are significant contributors to maternal morbidity and mortality, impacting an estimated 15% of delivery hospitalizations in the United States [1]. It is estimated that cardiovascular diseases constitute 26.5% of US pregnancy‐related deaths, the majority of which are due to acquired heart disease. HDP are strongly associated with severe maternal complications including acquired heart diseases such as heart attack and stroke [1, 2].

2. OBTAINING EXPERT CONSENSUS TO ADVANCE POSTPARTUM HYPERTENSION MONITORING AND MANAGEMENT

The American Medical Association (AMA) is the nation's largest physician organization and has supported physician‐led solutions to improve health outcomes. In 2024, they hosted a convening of clinical experts to assess and identify areas of consensus on postpartum blood pressure (BP) monitoring and management practices, including the use of self‐measured blood pressure (SMBP) and remote patient monitoring (RPM).

The 1‐day convening was held on May 14, 2024, in Chicago, Illinois and brought together 17 clinicians in maternal‐fetal medicine, obstetrics and gynecology, cardiology, primary care, public health, research, policy, and advocacy. Participants were selected based on their expertise and leadership in SMBP/RPM for HDP. Participants represented diverse organizations and geographic settings. AMA supported travel and honoraria for attendees. The meeting was moderated by Kara Hoppe, DO, PhD, with support from AMA staff in planning, facilitation, and documentation. All clinical experts and AMA staff attendant names, credentials, place of work, and expertise are detailed in Table S1.

Prior to the event, AMA staff conducted over 25 interviews with people identified as content experts based on prior research and/or development of innovations for postpartum hypertension care. Upon completion of the interviews, 17 topic experts were invited to participate in the convening. Additionally, the AMA staff including clinicians and external maternal‐fetal medicine subject matter expert, completed a review of the literature and finalized the key discussion topics identified for the convening: (1) inpatient/discharge BP treatment and goals, (2) patient identification for SMBP/RPM, (3) post‐discharge monitoring and treatment protocols, (4) review and response to BP results and team roles, (5) protocols and interventions for BP control after hospital discharge, and 6) home BP device selection. Specific questions were developed for each topic, and live polling captured the 17‐covening expert participants’ (Table S1) responses (Table 1). This convening did not follow a structured consensus‐building process as the goal was to elicit open discussion; however, participant consensus was generally considered at majority or a greater than 50% agreement in polling results. When there was no general agreement, the meeting moderators led structured discussions followed with breakout sessions for areas of disagreement. Final group discussions aimed to identify consensus and critical findings that were included in this final report.

TABLE 1.

Summary of polling questions and main results.

Polling questions (n = total survey respondents per question)	Responses Polling results % (total votes)
Postdelivery inpatient/discharge BP management and control goal
1. What is the postpartum BP at which treatment is started? (n = 17)	>130/80 12% (2)
	>140/90: 53% (9)
	>150/100: 18% (3)
	>160/100: 6% (1)
	No response: 12% (2)
2. For how long are patients at their BP goal prior to discharge? (n = 17)	At least one BP reading: 5% (1)
	12–24 h: 53% (9)
	>24 h: 24% (4)
	Other: 6% (1)
	No response: 12% (2)
Patient identification for SMBP/RPM
3. Which patients are enrolled in SMBP/RPM after discharge? (n = 17)	All patients using SMBP/RPM prenatally: 12% (2)
	All postpartum patients:18% (3)
	All patients diagnosed with HDP: 53% (9)
	Only patients on BP meds at discharge: 24% (4)
	Other: 6% (1)
	No response: 12% (2)
Post‐discharge BP monitoring and treatment protocols
4. How often are patients asked to measure their BP after discharge? (n = 17)	Daily: 75% (13)
	Every other day: 6% (1)
	Two to three times per week: 6% (1)
	Other: 6% (1)
	No response: 6% (1)
5. On days they measure, when are patients instructed to measure their BP each day? (n = 17)	In the morning only: 24% (4)
	In the evening: 0%
	In the morning and evening: 41% (7)
	Other: 12% (2)
	No response: 25% (4)
6. Are patients instructed to take more than one measurement at a time? (n = 17)	Yes: 41% (7)
	No: 47% (8)
	No response: 12% (2)
7. Is a medication treatment protocol used? (n = 17)	Yes: 53% Internally developed protocol: (7) Published protocol: (2)
	No: 29% (5)
	No response: 18% (3)
Review and response to patient BP results and clinical team roles
8. Who on the care team reviews patients’ BP results? (choose all that apply) (n = 16)	Physician overseeing SMBP/RPM: 38% (6)
	Primary OB provider: 44% (7)
	MFM/OB provider on‐call: 19% (3)
	Advanced practice provider overseeing SMBP/RPM program: 31% (5)
	Pharmacist: 6% (1)
	Registered nurse: 50% (8)
	Remote monitoring vendor/external team: 0%
	Other: 25% (4)
	No response: 13% (2)
9. How often are patients’ BP results reviewed? (n = 16)	Constantly during business hours: 31% (5)
	Twice daily: 0%
	Daily: 19% (3)
	Other: 37.5% (6)
	No response: 13% (2)
10. Is the BP monitoring protocol individualized during the first few weeks after discharge?  (n = 16)	Yes: 63% Based on the patient's BP results (6) Based on time (in days) after discharge (4)
	No: 37% (6)
Protocols and interventions for BP control after discharge
11. At what BP (mmHg) threshold is treatment initiated or titrated? (n = 17)	>130/80: 6% (1)
	>140/90: 76% (13)
	>150/100: 6% (1)
	>160/110: (0)
	Other: 6% (1)
	No response: 6% (1)
12. What occurs if a patient has a severe BP [5] result with symptoms? (n = 16)	Patient is sent to the ED: 59% (10)
	Patient is seen in‐person–clinic setting: 35% (6)
13. What occurs if a patient has a severe BP [5] result without symptoms? (n = 17)	BP measurement is repeated: 35% (6)
	Triage and treatment at home: 18% (3)
	Patient is sent to the emergency department: 18% (3)
	Patient is seen in‐person–clinic setting: 18% (3)
	Depends on BP result: 6% (1)
	No response: 6% (1)
14. When is medication tapered or stopped? (n = 13) (open response)	Not standardized: 23% (3)
	When BP decreases 8% (1)
	BP ≤ 120/80 15% (4)
	At 6 weeks if BP is normal with recheck in 1 week: 23% (3)
	BP persistently < 110/75 or symptomatic: 15% (2)
	Hypertension is no longer present: 8% (10)
	BP measurement is <130/80 for three measurements: 8% (1)
	Postpartum visit: 8% (1)
15. Who manages medication prescribing? (n = 17) (choose all that apply)	Physician Overseeing SMBP/RPM program: 53% (9)
	Primary OB provider: 47% (8)
	MFM/OB provider on‐call: 41% (7)
	Advanced practice provider overseeing SMBP/RPM program: 29% (5)
	Pharmacist: 12% (2)
	Registered nurse: 6% (1)
Home BP measurement device selection
16. Which BP Measurement device(s) do you use? (open question) (n = 16)	Whatever Insurance or grant funding supplies: 25% (5) Clinic/hospital availability or preference: 50% (8)
	Pharmacy availability: 6% (1)
	Uncertain: 6% (1)
	Device from VDL list: 6% (1)
	Common brands reported: Omeron, A&D, Microlife watch BP, iBloodPressure
17. Does the BP measurement device used have an XL cuff size available? (n = 16)	Yes: 69% (11) No: 6% (10) Unknown: 25% (4)
18. What functionality does the BP measurement device have? (choose all that apply) (n = 16)	BP results can be transmitted via Bluetooth: 31% (5)
	BP results can be transmitted via cellular data: 13% (2)
	BP results can be stored in the device: 19% (3)
	BP device can provide feedback to the patient on measurement result: 19% (3)
	No specific functionality: 25% (4)
19. How does the care team receive BP measurement data? (choose all that apply) (n = 16)	Care team conducts outreach to patients (phone, text, messaging): 44% (7)
	Results transmitted to an app/platform: 19% (3)
	Results transmitted directly into electronic medical record: 38% (6 votes)
	Results texted to care team: 31% (5)
	Results called in to care team: 31% (5)
	Patient manually enters into a portal: 19% (3)

Abbreviations: BP, blood pressure; HDP, hypertensive disorders of pregnancy; MFM, maternal fetal medicine provider; OB, obstetrician; RPM, remote patient monitoring; SMBP, self‐measured blood pressure; XL, extra‐large.

3. CURRENT GAPS IN POSTPARTUM HYPERTENSION CARE DELIVERY AND MANAGEMENT GUIDELINES

The Chronic Hypertension and Pregnancy (CHAP) trial demonstrated that maintaining BP <140/90 mmHg during pregnancy led to a reduced risk of preeclampsia with severe features occurring up to 2 weeks after birth, medically indicated preterm birth before 35 weeks’ gestation (i.e., because of maternal or fetal illness, not spontaneous labor or membrane rupture), placental abruption, or fetal or neonatal death [3]. Specific guidance for clinicians on postpartum BP management is limited. Treatment of severe hypertension, defined as BP ≥160/110 mmHg for greater than 15 min, in a hospital‐based setting is recommended within 60‐min. There is a lack of high‐quality evidence and consistent guidance regarding the optimal postpartum BP control goal; however, current evidence suggests that maintaining a postpartum BP goal of <140/90 may reduce postpartum readmission [4]. The 2025 Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines recommends that the overarching BP goal is <130/80 mmHg for all adults; however, there is a gap in evidence and guidance on when postpartum BP control goals should follow recommendations for non‐pregnant adults [5, 6].

Guidance on frequency, duration, and method of BP monitoring postpartum is also limited. ACOG recommends BP evaluation within 72‐h for patients with a history of severe hypertension and within 7–10 days for women with non‐severe‐range HDP [6]. Traditionally, BP evaluation is performed at an in‐person clinic visit; however, many of the in‐person visits are not completed. This has led to increasing support using SBPM as an alternate strategy to improve patient experience and engagement [6]. A systematic review demonstrated that SBPM likely improves ascertainment of BP in postpartum patients and can overcome inequities in office‐based follow‐up [4]. Existing home blood pressure monitoring (HBPM) and RPM programs have significant heterogeneity in the BP threshold for antihypertensive treatment initiation, maintenance goal, location of treatment for severe hypertension after discharge, team members who monitor incoming BP values, and use of RPM vendors or platforms. It is clear that a new paradigm of postpartum hypertension care is needed; this paper proposes recommendations based on expert opinions informed by clinical practice and utilization of the existing evidence.

4. SUMMARY OF OPINIONS FROM EXPERT CONVENING

4.1. Postdelivery inpatient BP management and discharge planning

Experts generally agreed that antihypertensive medications should be initiated for BP ≥140/90 mmHg postdelivery. The CHAP trial was cited as supporting evidence; however, experts acknowledged its limitations—such as inclusion of only patients with chronic hypertension and lack of generalizability to postpartum and all HDP types—yet recommendations were made despite these constraints.

³It was also noted that many patients experience increases in BP after hospital discharge, and waiting until the postpartum BP reaches higher levels makes BP control more difficult. A BP goal of <130/80 mmHg was considered too aggressive due to the dynamic physiological changes that occur postpartum and the risk of hypotension.

Many experts agreed that at least 12 h of inpatient BP monitoring after medication initiation or adjustment or an episode of severe hypertension requiring intravenous (IV) medications is needed to ensure that physicians, care team members, and patients have enough time to assess medication effectiveness prior to discharge.

Critical Finding: BP should be maintained at a goal of <140/90 for 12–24 h prior to hospital discharge.

4.2. Patient identification for SMBP for BP monitoring and management

Experts agreed that at the time of discharge, all patients with HDP should be provided with a home BP monitor, a supply of antihypertensive medications if indicated, comprehensive education on how to perform SMBP, and a plan to follow‐up BP within 24–48 h. Follow‐up BP plans included texts, phone calls, and virtual visits as alternatives to in‐person visits for BP assessment. RPM programs are becoming increasingly used to monitor BP postpartum; however, it was noted that these programs are often executed from academic centers with sufficient delivery volume, financial resources, and clinical infrastructure to support program development and management, including the use of external vendors or platforms.

Critical Finding: (1) All patients with HDP should be discharged with a home BP measurement device; (2) receive comprehensive education; (3) if possible, be enrolled in an RPM program; and (4) have their first interaction with the healthcare team after discharge within 24‐48 h.

4.3. Post‐discharge BP monitoring and treatment protocols

The experts in attendance who had developed RPM programs reported significant variation in BP monitoring protocols, including total times of day, total readings, and the interval of readings each time taken. Considerations for protocols include a patient's overall BP stability and ability to engage in SMBP and the timeframe in which the clinical team reviews and responds to BP results. It was generally agreed that BP monitoring twice a day is preferable; however, once a day may be more feasible for patients and the clinical team members responsible for reviewing and responding to results. Transitioning patients who need BP monitoring after the early postpartum period to a primary care or specialty provider for long‐term management is essential. For patients who develop chronic hypertension postpartum, the use of SMBP may continue as it is an evidence‐based strategy for the diagnosis, assessment, and management of BP in adults [4].

Critical Finding: (1) Post‐discharge BP monitoring should ideally be twice daily, but at a minimum once daily; (2) SMBP duration should occur for a minimum of 2 weeks postpartum; and (3) all patients who had an HDP should receive coordinated transition of care after the postpartum period for unresolved hypertension and long‐term cardiovascular surveillance.

4.4. Review and response to patient BP results and clinical team roles

A team‐based approach is generally utilized for SMBP/RPM programs to review and respond to BP results; however, it is acknowledged that there is significant variation in which care team members may be primarily responsible. Nurses are most often mentioned as the primary reviewers of SMBP results, while physicians, advanced practice providers, pharmacists, or nurses with delegation protocols or standing order sets may be medication prescribers. BP results are most typically reviewed during business hours, emphasizing the importance for patients to understand when their BP is monitored and how to respond to symptoms or abnormal BP readings outside of those hours. Automated responses may be a method to provide patient feedback and instructions for follow‐up when BP values are not at goal or team members are unavailable. Decisions regarding clinical team roles are often based on organizational structure and capacity.

Critical Finding: (1) Clinical team members responsible for BP monitoring and management may include physicians, advanced practice providers, pharmacists, or nurses. (2) These team members should receive training on postpartum BP goals and other clinical parameters that indicate when to escalate care.

4.5. Protocols and interventions for BP control after hospital discharge

Most participants agreed that antihypertensive medications should be initiated after discharge if BP exceeds 140/90 mmHg. Participants reported using both published and institutionally developed protocols for management of HBPM postpartum. Numerous single‐institution site trials/protocols have been published and are available for reference [6]. It was emphasized that treatment protocols should be designed for use by multiple members of a care team, including different disciplines and different roles. The duration of time to assess treatment effectiveness before making medication changes (e.g., initiation, intensification, or de‐escalation) should be included. Protocols should also address severe‐range BP evaluation and treatment. Recent expert opinion suggests that magnesium sulfate usage may be individualized in some experts’ opinions after the first 3 days postpartum [7]. Many clinician experts report successful treatment of asymptomatic patients with severe‐range BP after discharge. Further research is required to determine the best approach to risk reduction and treatment of severe‐range BPs, including evidence‐based outpatient assessment and treatment. It was recognized that increased HBPM monitoring in the postpartum period may lead to increased readmissions, hence the importance of a defined protocol to avoid unnecessary readmissions. Specific antihypertensive regimens and volume management strategies for protocols were outside the scope of this convening, however, important to consider when designing and implementing treatment protocols.

Critical Finding: (1) Treatment protocols are recommended prior to programmatic implementation of HBPM and should address management of severe hypertension.

4.6. Home BP measurement device selection

Participants reported barriers to HBPM included an insufficient number of US‐validated BP devices with a range of upper arm BP cuff sizes (specifically XL sizes) for pregnant persons, a lack of insurance coverage or access to coverage, and the high cost of available validated devices [8]. Due to the complexities of or a lack of coverage, many programs relied on grants or internal funding to pay for devices.

Critical Finding: All patients with HDP should have access to a validated home BP measurement device with an appropriately sized upper arm cuff prior to hospital discharge.

5. STRENGTHS AND LIMITATIONS

The convening included clinical and research experts who have made significant contributions to the literature in the content area of postpartum BP monitoring and management. While patients with lived experience were not included, their future involvement was acknowledged as essential. A structured consensus‐building process typically involves formal methods such as the Delphi technique, which uses multiple rounds of anonymous surveys to gather expert opinions, followed by iterative feedback and ranking to achieve consensus. This convening did incorporate elements of a modified Delphi approach (such as an anonymous survey to gather expert opinions, face‐to‐face discussion, and a predefined consensus definition of ≥50% agreement), but did not complete the formal structured consensus‐building process as the goal was to elicit open discussion among experts and time was limited. However, the topics and polling questions were generated after extensive background research, including a scoping review of the literature and interviews with subject matter experts. The findings uncovered through the discussion considered current evidence and practice recommendations and are intended to provide a starting point for future guideline development, research, and policymaking.

6. RECOMMENDATIONS FOR RESEARCH AND POLICY

The need for continued research into the most effective strategies and interventions to improve postpartum BP monitoring, management, and treatment protocols was clear. Additionally, evaluation of the effect of SMBP/RPM on long‐term cardiovascular outcomes is recommended. Efforts to increase availability and access to validated BP devices during pregnancy and postpartum were identified as a policy priority. Additionally, as artificial intelligence and cuffless wearable devices are becoming increasingly recognized for their potential to aid in BP monitoring, the consideration and inclusion of pregnant and postpartum patients in design, evaluation, and adoption is needed. Incentives to invest in the integration of digital health and the development of optimal clinical infrastructure for the management and treatment of BP postpartum are also essential.

7. IMPLICATIONS FOR CLINICAL PRACTICE

There were multiple critical findings for postpartum BP monitoring and management, which suggested areas of consensus, as outlined in Table 2. The management of HDP and BP in the postpartum period impacts short‐term and long‐term health of the birthing population. Transformative approaches to BP monitoring and management are needed along with further research and policy efforts to establish standards of care for postpartum HDP and improve maternal health in the United States.

TABLE 2.

Summary of critical findings for postpartum BP monitoring and management.

	Postpartum period: Location of care
Categories of hypertension management	Postdelivery inpatient hospitalization	Home/after discharge through 6 weeks postpartum a
BP treatment goals and thresholds
BP control	<140/90 mmHg	<140/90 mmHg
Intervention for Severe BP (160/110 mmHg) confirmed on two occasions at least 15 min apart21
Severe hypertension	a Per ACOG guidelines, treatment within 30–60 min with IV/PO medications	Immediate assessment: May include in‐person evaluation and treatment or home treatment with RPM surveillance
BP monitoring and treatment protocols
Duration of hospital stay once BP goal obtained/control achieved	12–24 h	–
Frequency of BP monitoring	Follow inpatient protocol ‐AND‐ Educate on SMBP frequency at home prior to hospital discharge	Minimum daily, optimal twice daily
Time to first interaction with healthcare team after discharge	–	Within 24–48 h
Duration of SMBP/RPM	–	At least 2 weeks postpartum, up to 6 weeks may be preferred
BP measurement devices
Home BP measurement devices	Provide patients with a validated home BP measurement device with an appropriately sized upper cuff at the time of discharge. Consider prescribing BP measurement device prenatally to ensure all patients receive them and are ready for use postpartum.	Use a validated home BP measurement device with an appropriately sized upper arm cuff through the postpartum period
Clinical team roles
BP monitoring and management responsibility	–	Team‐based care recommended Provider options include physician, advanced practice provider, pharmacist, and nurse

Note: Intervention for severe BP (160/110 mmHg) was defined per ACOG as ≥160 mmHg or diastolic blood pressure ≥110 mmHg, measured on two occasions at least 15 min apart.

Abbreviations: ACOG, American College of Obstetricians and Gynecologists; BP, blood pressure; IV, intravenous; PO, oral; RPM, remote patient monitoring; SMBP, self‐measured blood pressure.

^a The recommendations are limited to the 6‐week postpartum period. The exact transition period to the following BP goals recommended by ACC/AHA for non‐pregnant adults is not defined.

CONFLICT OF INTEREST STATEMENT

Kara Hoppe is an employee of the University of Wisconsin‐Madison School of Medicine and Public Health and UW Health. Neha Sachdev, Klodiana Myftari, Tamkeen Khan, Michael Rakotz, Rupi Hayer, Rosaura Vidal, and Siga Vasaitis are all employees of the AMA.

FUNDING INFORMATION

The AMA had an agreement in place with Kara Hoppe and provided financial support to help provide subject matter expertise on the structure of the convening and serve as the convening moderator.

Supporting information

Supporting Information