Cardiovascular severe maternal morbidity in pregnant and postpartum women: development and internal validation of risk prediction models

Malhamé, Isabelle; Danilack, Valery A.; Raker, Christina; Hardy, Erica; Spalding, Hannah; Bouvier, Benjamin; Hurlburt, Heather; Vrees, Roxanne; Savitz, David A.; Mehta, Niharika

doi:10.1111/1471-0528.16512

Cited by 20 publications

(13 citation statements)

References 49 publications

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“…The incidence of hypertension-related cardiovascular morbidities, such as obstetric hypertensive emergency, stroke, and heart failure, is highest during the postpartum period [41][42][43][44][45][46]. Moreover, preeclampsia at the time of delivery is the strongest risk factor for postpartum readmission with cardiovascular morbidity within 6 weeks postpartum [47], and hypertension is a leading cause of hospital readmission and healthcare resource utilization during the postpartum period [41,48,49]. Thus, strategies to optimize postpartum BP management are needed.…”

Section: Discussionmentioning

confidence: 99%

The use of loop diuretics in the context of hypertensive disorders of pregnancy: a systematic review and meta-analysis

Malhamé

Dong

Syeda

et al. 2022

Journal of Hypertension

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Aims: Addressing volume expansion may improve the management of hypertension across the pregnancy continuum. We conducted a systematic review to summarize the evidence on the use of loop diuretics in the context of hypertensive disorders during pregnancy and the postpartum period.Methods and results: Medline, Embase, Cochrane library, ClinicalTrials.gov, and Google Scholar were searched for original research articles published up to 29 June 2021. Of the 2801 results screened, 15 studies were included: eight randomized controlled trials, six before-after studies, and one cohort study. Based on random effects meta-analysis of before-after studies, antepartum use of loop diuretics was associated with lower DBP [mean difference À17.73 mmHg, (95% confidence intervals À34.50 to À0.96); I 2 ¼ 94%] and lower cardiac output [mean difference À0.75 l/min, (À1.11 to À0.39); I 2 ¼ 0%], with no difference in SBP, mean arterial pressure, heart rate, or total peripheral resistance. Meta-analysis of randomized controlled trials revealed that postpartum use of loop diuretics was associated with decreased need for additional antihypertensive patients [relative risk 0.69, (0.50-0.97); I 2 ¼ 14%], and an increased duration of hospitalization [mean difference 8.80 h, (4.46-13.14); I 2 ¼ 83%], with no difference in the need for antihypertensive therapy at hospital discharge, or persistent postpartum hypertension.Conclusion: Antepartum use of loop diuretics lowered DBP and cardiac output, while their postpartum use reduced the need for additional antihypertensive medications. There was insufficient evidence to suggest a clear benefit. Future studies focusing on women with hypertensive pregnancy disorders who may most likely benefit from loop diuretics are required.

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Section: Discussionmentioning

confidence: 99%

The use of loop diuretics in the context of hypertensive disorders of pregnancy: a systematic review and meta-analysis

Malhamé

Dong

Syeda

et al. 2022

Journal of Hypertension

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“…APOs are a well-established and leading cause of maternal morbidity and mortality in the short term during and following pregnancy. 5,48,49 An emerging body of evidence demonstrates that APOs are additionally associated with development of CVD risk factors and CVD across the life course. 5,14,50–53 APOs and CVD share common risk factors, 54,55 which may be due to overlapping pathophysiologic mechanisms.…”

Section: Apos Cvd Risk Factors and Cvd Riskmentioning

confidence: 99%

Pregnancy as an Early Cardiovascular Moment: Peripartum Cardiovascular Health

Khan

Cameron

Lindley

2023

Circulation Research

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Pregnancy is commonly referred to as a window into future CVH (cardiovascular health). During pregnancy, physiological adaptations occur to promote the optimal growth and development of the fetus. However, in approximately 20% of pregnant individuals, these perturbations result in cardiovascular and metabolic complications, which include hypertensive disorders of pregnancy, gestational diabetes, preterm birth, and small-for-gestational age infant. The biological processes that lead to adverse pregnancy outcomes begin before pregnancy with higher risk of adverse pregnancy outcomes observed among those with poor prepregnancy CVH. Individuals who experience adverse pregnancy outcomes are also at higher risk of subsequent development of cardiovascular disease, which is largely explained by the interim development of traditional risk factors, such as hypertension and diabetes. Therefore, the peripartum period, which includes the period before (prepregnancy), during, and after pregnancy (postpartum), represents an early cardiovascular moment or window of opportunity when CVH should be measured, monitored, and modified (if needed). However, it remains unclear whether adverse pregnancy outcomes reflect latent risk for cardiovascular disease that is unmasked in pregnancy or if adverse pregnancy outcomes are themselves an independent and causal risk factor for future cardiovascular disease. Understanding the pathophysiologic mechanisms and pathways linking prepregnancy CVH, adverse pregnancy outcomes, and cardiovascular disease are necessary to develop strategies tailored for each stage in the peripartum period. Emerging evidence suggests the utility of subclinical cardiovascular disease screening with biomarkers (eg, natriuretic peptides) or imaging (eg, computed tomography for coronary artery calcium or echocardiography for adverse cardiac remodeling) to identify risk-enriched postpartum populations and target for more intensive strategies with health behavior interventions or pharmacological treatments. However, evidence-based guidelines focused on adults with a history of adverse pregnancy outcomes are needed to prioritize the prevention of cardiovascular disease during the reproductive years and beyond.

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“…13 Recently, predictive models have been developed for low frequency postpartum complications, 14 including postpartum haemorrhage, 15 infectious morbidity, 16 venous thromboembolism 17 and cardiovascular diseases. 18,19 The objective of the current study was to develop and internally validate a predictive model for postpartum readmission for hypertension and pre-eclampsia at delivery discharge.…”

Section: Introductionmentioning

confidence: 99%

“…A useful model may include variables that are readily available in the electronic health record (EHR) 13 . Recently, predictive models have been developed for low frequency postpartum complications, 14 including postpartum haemorrhage, 15 infectious morbidity, 16 venous thromboembolism 17 and cardiovascular diseases 18,19 …”

Section: Introductionmentioning

confidence: 99%

Postpartum readmission for hypertension and pre‐eclampsia: development and validation of a predictive model

Venkatesh

Jelovsek

Hoffman

et al. 2023

BJOG

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ObjectiveTo develop a model for predicting postpartum readmission for hypertension and pre‐eclampsia at delivery discharge and assess external validation or model transportability across clinical sites.DesignPrediction model using data available in the electronic health record from two clinical sites.SettingTwo tertiary care health systems from the Southern (2014–2015) and Northeastern USA (2017–2019).PopulationA total of 28 201 postpartum individuals: 10 100 in the South and 18 101 in the Northeast.MethodsAn internal‐external cross validation (IECV) approach was used to assess external validation or model transportability across the two sites. In IECV, data from each health system were first used to develop and internally validate a prediction model; each model was then externally validated using the other health system. Models were fit using penalised logistic regression, and accuracy was estimated using discrimination (concordance index), calibration curves and decision curves. Internal validation was performed using bootstrapping with bias‐corrected performance measures. Decision curve analysis was used to display potential cut points where the model provided net benefit for clinical decision‐making.Main outcome measuresThe outcome was postpartum readmission for either hypertension or pre‐eclampsia <6 weeks after delivery.ResultsThe postpartum readmission rate for hypertension and pre‐eclampsia overall was 0.9% (0.3% and 1.2% by site, respectively). The final model included six variables: age, parity, maximum postpartum diastolic blood pressure, birthweight, pre‐eclampsia before discharge and delivery mode (and interaction between pre‐eclampsia × delivery mode). Discrimination was adequate at both health systems on internal validation (c‐statistic South: 0.88; 95% confidence interval [CI] 0.87–0.89; Northeast: 0.74; 95% CI 0.74–0.74). In IECV, discrimination was inconsistent across sites, with improved discrimination for the Northeastern model on the Southern cohort (c‐statistic 0.61 and 0.86, respectively), but calibration was not adequate. Next, model updating was performed using the combined dataset to develop a new model. This final model had adequate discrimination (c‐statistic: 0.80, 95% CI 0.80–0.80), moderate calibration (intercept −0.153, slope 0.960, Emax 0.042) and provided superior net benefit at clinical decision‐making thresholds between 1% and 7% for interventions preventing readmission. An online calculator is provided here.ConclusionsPostpartum readmission for hypertension and pre‐eclampsia may be accurately predicted but further model validation is needed. Model updating using data from multiple sites will be needed before use across clinical settings.

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Cardiovascular severe maternal morbidity in pregnant and postpartum women: development and internal validation of risk prediction models

Cited by 20 publications

References 49 publications

The use of loop diuretics in the context of hypertensive disorders of pregnancy: a systematic review and meta-analysis

The use of loop diuretics in the context of hypertensive disorders of pregnancy: a systematic review and meta-analysis

Pregnancy as an Early Cardiovascular Moment: Peripartum Cardiovascular Health

Postpartum readmission for hypertension and pre‐eclampsia: development and validation of a predictive model

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