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Published in final edited form as: J Obstet Gynecol Neonatal Nurs. 2023 Nov 22;53(2):132–139. doi: 10.1016/j.jogn.2023.11.002

Association Between Recurrent Preeclampsia and Attendance at the Blood Pressure Monitoring Appointment After Birth

Eleanor Saffian 1, Anna Palatnik 2
PMCID: PMC10939826  NIHMSID: NIHMS1955652  PMID: 38006903

Abstract

Objective:

To examine the association between recurrent preeclampsia and attendance at the standard of care blood pressure monitoring appointment after birth.

Design:

Retrospective cohort.

Setting:

Single Magnet-accredited hospital affiliated with an academic medical center.

Participants:

Multiparous women who gave birth between 2010 and 2020 and were diagnosed with preeclampsia (N = 313).

Methods:

We divided participants into two groups: those with prior preeclampsia (n = 119) and those without prior preeclampsia (n = 194). Using logistic regression, we calculated unadjusted and adjusted odds ratios to estimate the association between attendance at the postpartum blood pressure (PPBP) monitoring appointment and prior preeclampsia. We also explored the relationship between attendance at the PPBP monitoring appointment and use of magnesium sulfate during labor and birth and the relationship between attendance at the PPBP monitoring appointment and use of maintenance antihypertensive medications.

Results:

In adjusted analysis, participants with prior preeclampsia were 66.4% less likely to attend the PPBP monitoring appointment compared with those without prior preeclampsia, AOR = 0.34, 95% CI [0.18, 0.62]. Administration of magnesium sulfate during labor and use of maintenance antihypertensive medications were not associated with a change in attendance at the PPBP appointment.

Conclusion:

Further research on patient-perceived risk of recurrent preeclampsia and improvement of systems to facilitate postpartum follow-up is needed.

Keywords: recurrent preeclampsia, postpartum, appointment attendance

Precis

Recurrent preeclampsia was associated with significantly reduced odds of attending the postpartum blood pressure monitoring appointment.

Preeclampsia is a pregnancy-related condition of persistently elevated blood pressures (≥140/90 mmHg) with symptoms of end organ damage (American College of Obstetricians and Gynecologists (ACOG), 2018). Preeclampsia affects as many as 8% of pregnant women and is one of the leading causes of maternal mortality (Ma’ayeh & Costantine, 2020). Besides the immediate risk of maternal morbidity and mortality secondary to seizure and stroke, preeclampsia has long term health implications because it is linked to the development of cardiovascular disease later in life (Norwitz, n.d.), specifically ischemic heart disease and chronic hypertension (Brouwers et al., 2018; Garovic et al., 2020; Leon et al., 2019), and kidney disease (Garovic et al., 2020). Preeclampsia can increase the risk of adverse fetal outcomes, including fetal growth restriction (Dapkekar et al., 2023), oligohydramnios, and iatrogenic preterm birth (ACOG, 2020; Dapkekar et al., 2023).

Callout 1

Current recommendations for addressing preeclampsia primarily focus on managing symptoms; childbirth is the only known cure (Dimitriadis et al., 2023). During the immediate postpartum period and during in-patient care, blood pressure should be closely monitored, and if persistently within a severe range (systolic ≥160 mmHg and/or diastolic ≥110 mmHg), medical management with magnesium sulfate and maintenance antihypertensive medications should be used. Magnesium sulfate increases the seizure threshold for patients with preeclampsia with severe features (ACOG, 2020; Bartal & Sibai, 2022; Brookfield et al., 2021; Okonkwo & Nash, 2022). Severe features of preeclampsia include signs of end organ damage such as proteinuria, elevated liver function tests, low platelets, elevated creatinine, and more. Current guidelines regarding the use of antihypertensive medications are vague, but it is broadly recommended to prescribe antihypertensive medications if blood pressures are persistently severe. Some experts recommend starting treatment at 150/100 mmHg (ACOG, 2020; Hauspurg & Jeyabalan, 2022).

Blood pressures reach a peak approximately 4 to 7 days after childbirth, at which point the patient has most likely been discharged from the hospital (Kumar et al., 2022; Magee et al., 2014; Mukhtarova et al., 2021; Ngene, 2019). The ACOG (2018, p. e143) indicated that to optimize postpartum care, “blood pressure evaluation is recommended for women with hypertensive disorders of pregnancy no later than 7–10 days postpartum, and women with severe hypertension should be seen within 72 hours.” Other experts recommended follow-up at 3 to 5 days (National Institute for Health and Care Excellence, 2023). Such assessment is critical given that more than one half of postpartum strokes occur within 10 days of discharge (Too et al., 2018).

While guidelines from ACOG and National Institute for Health and Care Excellence support standardization of postpartum blood pressure monitoring, attendance at the postpartum blood pressure (PPBP) appointment and factors that contribute to this attendance rate must be further evaluated. This follow-up appointment occurs at a critical time and has the potential to significantly improve maternal outcomes because it presents an opportunity for medical professionals to assess patients and intervene if indicated. Persistent hypertension indicates a continued risk of maternal morbidity and mortality. Maternal characteristics associated with a decreased rate of attendance at the PPBP monitoring appointment have been reported as race, ethnicity, insurance status (Attanasio, 2022; Danilack et al., 2019; Tallmadge et al., 2021), age, education, income, marital status, and smoking status (Danilack et al., 2019). However, another important factor, recurrence of preeclampsia in a subsequent pregnancy, has yet to be assessed in terms of its relationship to postpartum care. This factor is significant because in three studies, 10.5% to 29% of women experienced recurrence of preeclampsia (10.5%: Bernardes et al., 2019; 20%–29%: Mulder et al., 2018; 17.1%: Wainstock & Sheiner, 2022). The risk of recurrence was correlated with the severity of the hypertensive disorder of pregnancy (Bernardes et al., 2019). In this study we examined the association between recurrent preeclampsia and attendance at the standard of care blood pressure monitoring appointment after birth. We hypothesized that women who experienced and survived preeclampsia in the past might develop a false sense of security and believe that postpartum monitoring is not essential.

Methods

Design

We conducted a retrospective cohort study using data from the electronic health record. The Medical College of Wisconsin Institutional Review Board approval was obtained before we began the study.

Setting

This study was conducted at a single Magnet-accredited hospital affiliated with an academic medical center staffed by maternal-fetal medicine specialists, obstetricians, and clinical nurse midwives. As of 2022, this facility supports 3,600 births annually. With a level IV neonatal intensive care unit attached to the birth center, holistic low- and high-risk antepartum, intrapartum, and postpartum care is provided. The birth center includes three operating rooms and 17 labor and delivery beds.

Participants

This study included 313 participants diagnosed with preeclampsia in the index pregnancy between 2010 and 2020. Inclusion criteria included diagnosis of preeclampsia (with or without severe features) or hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome using ACOG criteria (ACOG, 2020). Definitions of hypertensive conditions are shown in Supplementary Table S1. All participants were multiparous. Exclusion criteria included nulliparity, chronic hypertension, gestational hypertension, and incomplete or missing data. Twenty-six participants had incomplete data, defined as missing obstetric data or postpartum appointment scheduling/attendance information.

Data Collection

This study was a secondary analysis of a cohort study on the association between exposure to green space and incidence of preeclampsia. Electronic medical records of patients diagnosed with preeclampsia or gestational hypertension using ACOG criteria and who gave birth at Froedtert birth center were identified using Clinical Data Warehouse. This secondary analysis was limited to a subgroup of patients who had prior childbirth and had available information in the medical records regarding prior obstetric history and whether prior pregnancy was complicated by preeclampsia.

Measures

We extracted data on individual characteristics and birth outcomes. Individual characteristics included history of preeclampsia in prior pregnancy, maternal age, race, ethnicity, marital status, insurance status, and management of preeclampsia in the index pregnancy. Birth outcomes included mode of childbirth and gestational age at childbirth. The primary outcome was the rate of attendance at the standard of care PPBP monitoring appointment. We used a binary variable in the analysis in which 1 = attended the PPBP monitoring appointment and 0 = did not attend the appointment. The primary predictor variable was recurrent preeclampsia (1 = multiparous with preeclampsia diagnosis in index pregnancy and prior pregnancy and 0 = multiparous with first occurrence of preeclampsia in index pregnancy). Secondary predictors were use of magnesium sulfate during labor (1 = magnesium sulfate was administered during labor and delivery admission and 0 = magnesium was not administered) and use of maintenance antihypertensive medications as markers for preeclampsia severity (1 = scheduled antihypertensive medications were prescribed during labor and delivery admission and continued after birth and 0 = scheduled antihypertensive medications were not prescribed at any point during admission and/or time of discharge from birth admission).

Analysis

We calculated descriptive statistics on the sample and study variables. We conducted unpaired t-test, Wilcoxon rank-sum test, and chi-square tests to compare the two study cohorts and assess for statistically significant difference in variable frequency. We conducted logistic regression using unadjusted and adjusted models to estimate (a) the relationship between attendance at the PPBP monitoring appointment and recurrent preeclampsia (b) the relationship between attendance at the PPBP monitoring appointment and use of magnesium sulfate during labor and birth and (c) the relationship between attendance at the PPBP monitoring appointment and use of maintenance antihypertensive medications. In the adjusted models, we performed a logistic regression and controlled for the following covariates: maternal age, maternal race and ethnicity, insurance status, marital status, mode of childbirth, and the gestational age at birth. We calculated odds ratios and adjusted odds ratios with 95% confidence intervals where the statistical significance was set at p < 0.05 for a two-tailed test. The analysis was conducted in SAS version 9.4 (SAS Institute, Cary, NC).

Callout 2

Results

Of the 313 multiparous participants who were diagnosed with preeclampsia with or without severe features during the index pregnancy, 119 (38.0%) had prior preeclampsia while 194 (62.0%) were diagnosed with preeclampsia before the index pregnancy (Supplementary Figure S1). The characteristics of the sample are described in Table 1. Participants who did not attend the PPBP appointment were more likely to be Black, have a lower mean age, have public insurance, be unmarried, and have vaginal birth.

Table 1.

Sample Characteristics and Birth Outcomes Stratified by Postpartum Blood Pressure Monitoring Appointment Attendance.

Did not attend PPBP appointment (N = 123)
n (%)		 Attended PPBP appointment (N = 190)
n (%)		 p
Prior preeclampsia 0.004a
 No 64 (52.0) 130 (68.4)
 Yes 59 (48.0) 60 (31.6)
Demographics and characteristics
 Age, years M (SD) 30.1 (5.5) 32.7 (42.7) <0.001b
 Race and Ethnicity 0.04a
  Black 71 (57.7) 86 (45.3)
  White 37 (30.1) 84 (44.2)
  Hispanic/Other 15 (12.2) 20 (10.5)
 Insurance status 0.002b
  Private 34 (27.9) 86 (45.5)
  Public 88 (72.1) 103 (54.5)
 Marital status <0.001a
  Married 36 (36.0) 87 (57.2)
  Single 64 (64.0) 65 (42.8)
Birth outcomes
 Mode of childbirth 0.03a
  Vaginal 77 (62.6) 95 (50.0)
  Cesarean 46 (37.4) 95 (50.0)
 Gestational age at birth, weeks M (SD) 36.4 (3.1) 36.2 (2.9) 0.25b
 Magnesium administration during admission 0.33a
  No 53 (43.1) 71 (37.6)
  Yes 70 (56.9) 118 (62.4)
Prescribed antihypertensive pharmacotherapy 0.35a
  No 73 (59.3) 203 (54.0)
  Yes 50 (40.7) 87 (46.0)
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a

Chi-square test.

b

Wilcoxon rank-sum test.

In unadjusted analysis, participants with recurrent preeclampsia were 50.0% less likely to attend the PPBP monitoring appointment compared with those without prior preeclampsia (OR = 0.50, 95% CI [0.31, 0.80]; Table 2). In the adjusted analysis, participants diagnosed with recurrent preeclampsia were 66.0% less likely to attend the PPBP monitoring appointment than those who did not have prior preeclampsia (AOR = 0.34, 95% CI [0.18, 0.62]). The two secondary endpoints were not correlated with appointment attendance (Table 2).

Table 2.

Association Between Attending the PPBP Monitoring Appointment and History of Preeclampsia, Magnesium Sulfate Administration, and Prescribing of Antihypertensive Medication

Variable OR [95% CI] p Adjusted ORa [95% CI] p
History of preeclampsia 0.50 [0.31–0.80] 0.004 0.34 [0.18–0.62] <0.001
Magnesium administration during admission 1.26 [0.79–2.00] 0.33 1.15 [0.60–2.18] 0.68
Antihypertensive maintenance medication prescribed 1.25 [0.79–1.97] 0.35 1.23 [0.68–2.23] 0.50
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Note. OR = Odds ratio. Bold represents statistical significance.

a

Adjusted for maternal age, race, ethnicity, insurance type, marital status, mode of childbirth, and gestational age at birth.

Discussion

We found that participants with recurrent preeclampsia were significantly less likely to attend the PPBP monitoring appointment than participants without prior preeclampsia. While researchers have investigated factors associated with decreased postpartum appointment attendance, they did not examine recurrent preeclampsia (Attanasio, 2022; Danilack et al., 2019; Hirshberg et al., 2019; Steele et al., 2023; Tallmadge et al., 2021). We identified another group of patients at risk of being lost to follow-up after hypertensive pregnancy.

Neither use of magnesium sulfate during labor nor use of maintenance antihypertensive maintenance medications, which served as markers for hypertensive disease severity, were significantly associated with a difference in the rate of attendance at the PPBP monitoring appointment. Interestingly, other researchers found that increased severity of hypertensive disorders of pregnancy (Supplementary Table S1) was associated with improved attendance at appointments after birth (Campbell et al., 2022; Li et al., 2023; Tallmadge et al., 2021). Li et al. (2023) and Tallmadge et al. (2021) analyzed the effect of administration of magnesium sulfate on appointment attendance. While the latter researchers reported statistical significance that indicated an association between administration of magnesium sulfate and improved appointment attendance, the former did not. This may be explained by the fact that patients did not associate the administration of magnesium sulfate with severity of hypertensive disorders of pregnancy. Maternity care clinicians recognize the association between the use of magnesium sulfate and preeclampsia with severe features, but this association may not be evident to a lay person. Regarding the use of maintenance antihypertensive medications, Campbell et al. (2022) and Tallmadge et al. (2021) reported significant improvement in postpartum appointment attendance for those who were prescribed maintenance antihypertensive medications. Steele et al. (2023) assessed this variable but did not report a significant effect on postpartum appointment attendance, which is similar to our findings. This discordance may be explained by the lack of standardization for prescribing maintenance antihypertensive medication.

Callout 3

Limitations

Several limitations of our study should be noted. First, we did not collect data on disease severity in the prior pregnancy. Second, we do not have data on the social determinants of health that influence attendance at postpartum care appointments and compliance with recommended care, including transportation, support systems and childcare, distance from residence to obstetric office, and length of maternity leave. It is possible that participants with recurrent preeclampsia had more social risk factors that were associated with recurrent preeclampsia and with difficulties accessing postpartum care. Third, we examined data from 2010 to 2020, a span of time before our health care system added remote PPBP monitoring and the option of virtual postpartum visits. Thus, our data apply only to in-person visits. Further research is needed to examine whether the risk of missing the PPBP monitoring appointment among patients with recurrent preeclampsia applies to virtual visits.

Implications

The explanation for the observed association of decreased attendance at the PPBP monitoring appointment with recurrent preeclampsia is of particular concern and deserves further investigation because in multiple studies, researchers found increased risk of future cardiovascular disease with recurrent preeclampsia (Brouwers et al., 2018; Stuart et al., 2018; Venetkoski et al., 2022). Therefore, women’s perceptions of preeclampsia and their level of risk for adverse postpartum outcomes require further research and examination. In one prospective cohort study, Traylor et al. (2016) surveyed women diagnosed with hypertensive disorders of pregnancy and assessed their knowledge of future risk of cardiovascular disease. These Recurrent preeclampsia and appointment attendance researchers reported that participants diagnosed with preeclampsia with severe features and those who gave birth preterm were more aware of increased risk of recurrent hypertensive disorders in future pregnancies and hypertension later in life than those with less severe hypertensive disorders of pregnancy and those who gave birth at term gestation (≥37 weeks of gestation). Additionally, participants who gave birth preterm were significantly more aware of increased risk for myocardial infarction and stroke later in life. Neither a history of preeclampsia nor rate of postpartum appointment attendance were assessed by Traylor et al. (2016). Future researchers should examine whether severity of preeclampsia in a prior pregnancy or first pregnancy outcomes, such as preterm birth or NICU admission, modify this association. For instance, it is possible that women with recurrent preeclampsia but overall favorable pregnancy outcomes in prior pregnancy would be falsely reassured and less concerned if they develop recurrent preeclampsia. Researchers investigated perceived risk of future CVD without considering history of preeclampsia in prior pregnancy (Traylor et al., 2016); therefore, perceived risk after recurrent diagnoses of hypertensive disorder of pregnancy warrants further investigation. This area of future research presents an opportunity to provide targeted education on recurrent risk of preeclampsia to preeclampsia survivors and to improve systems to facilitate postpartum follow-up and linkage to long-term cardiovascular follow-up.

One way to improve attendance at the PPBP monitoring appointment is to convert this follow-up appointment to a virtual visit. Virtual health care programs have been created to address barriers that impede attendance at postpartum appointments and support equitable access to health care for all. Research clearly shows that women from racial minorities and those with lower socioeconomic status disproportionately experience adverse birth outcomes (Admon et al., 2018; Grobman et al., 2018; Howell et al., 2018; Wang et al., 2020). These same women are less likely to attend the postpartum visits (Attanasio, 2022; Danilack et al., 2019; Hirshberg et al., 2019; Steele et al., 2023; Tallmadge et al., 2021). To address this known disparity, many health care facilities are implementing phone app-based platforms to support remote monitoring of blood pressures (Hauspurg et al., 2019; Hirshberg et al., 2019; Hoppe et al., 2020). Steele et al. (2023) conducted a systematic review of research initiatives to evaluate the effects of postpartum home BP monitoring and concluded that moderate strength evidence shows that home BP monitoring improves availability of BP data when compared to office-based follow-up without home monitoring. Additionally, Steele et al. (2023) concluded that moderate strength evidence shows a reduction in racial disparities with home monitoring.

In 2022, our hospital implemented a remote blood pressure program. The hospital has partnered with Inception Health and Babyscripts, a commercial program that provides a hypertension monitoring platform. Patients are prompted to check their blood pressure via a home blood pressure cuff and to enter the recording into the app. Blood pressures are monitored through a call center for the first 16 days after birth. If the measured blood pressure is severe and/or preeclampsia symptoms are present, the app triggers a phone call to the patient’s provider with a notification that the patient needs to be promptly contacted and assessed. This virtual follow-up may eliminate some of the barriers to attendance at the PPBP monitoring appointment.

Conclusion

In this retrospective cohort study, we found that recurrent preeclampsia was associated with a significantly lower rate of attendance at the PPBP monitoring appointment. Further research on patient-perceived risk of recurrent preeclampsia and improvement of systems to facilitate postpartum follow-up is needed.

Supplementary Material

1

Callouts:

  1. Blood pressures reach a peak approximately 4 to 7 days after childbirth, at which point women have most likely been discharged from the hospital.

  2. Participants with prior preeclampsia were 66.4% less likely to attend the postpartum blood pressure monitoring appointment.

  3. Further research on patient-perceived risk of recurrent preeclampsia and improved systems to facilitate postpartum follow-up are needed.

Funding

Supported by the National Center for Advancing Translational Sciences, National Institutions of Health (NIH), through Grant Number UL1 TR001436. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Footnotes

Disclosure

The authors report no conflicts of interest or relevant financial relationships.

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Contributor Information

Eleanor Saffian, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI..

Anna Palatnik, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI..

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