Preeclampsia: a report and recommendations of the workshop of the Society for Maternal-Fetal Medicine and the Preeclampsia Foundation

Louis, Judette; Parchem, Jacqueline G.; Vaught, Arthur J.; Tesfalul, Martha; Kendle, Anthony; Tsigas, Eleni

doi:10.1016/j.ajog.2022.06.038

Cited by 11 publications

(6 citation statements)

References 169 publications

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“…13 Postpartum care guidelines in the United States for patients with hypertension recommend a BP check 3-10 days after delivery; however, some studies show that 60% of readmissions occur before an outpatient postpartum visit. [14][15][16] Remote BP monitoring after discharge has been associated with a reduction in readmissions compared with standard outpatient care. 17 In light of these studies evaluating inpatient and outpatient care of patients with hypertension, we enacted a standardized clinical assessment and management plan at our institution targeting lower BP goals while incorporating close outpatient remote BP monitoring with similar targets.…”

Section: Resultsmentioning

confidence: 99%

“…13 Postpartum care guidelines in the United States for patients with hypertension recommend a BP check 3–10 days after delivery; however, some studies show that 60% of readmissions occur before an outpatient postpartum visit. 14–16 Remote BP monitoring after discharge has been associated with a reduction in readmissions compared with standard outpatient care. 17…”

mentioning

confidence: 99%

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Standardized Clinical Assessment and Management Plan to Reduce Readmissions for Postpartum Hypertension

Mei

Corry-Saavedra

Nguyen

et al. 2023

Obstetrics &Amp; Gynecology

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OBJECTIVE: To evaluate the effect of a postpartum hypertension standardized clinical assessment and management plan on postpartum readmissions and emergency department (ED) visits. METHODS: We conducted a prospective cohort study of patients with postpartum hypertension (either chronic hypertension or hypertensive disorders of pregnancy) who delivered at a single tertiary care center for 6 months after enacting an institution-wide standardized clinical assessment and management plan (postintervention group). Patients in the postintervention group were compared with patients in a historical control group. The standardized clinical assessment and management plan included 1) initiation or uptitration of medication for any blood pressure (BP) higher than 150/100 mm Hg or any two BPs higher than 140/90 mm Hg within a 24-hour period, with the goal of achieving normotension (BP lower than 140/90 mm Hg) in the 12 hours before discharge; and 2) enrollment in a remote BP monitoring system on discharge. The primary outcome was postpartum readmission or ED visit for hypertension. Multivariable logistic regression was used to evaluate the association between standardized clinical assessment and management plan and the selected outcomes. A sensitivity analysis was performed with propensity score weighting. A planned subanalysis in the postintervention cohort identified risk factors associated with requiring antihypertensive uptitration after discharge. For all analyses, the level of statistical significance was set at P<.05. RESULTS: Overall, 390 patients in the postintervention cohort were compared with 390 patients in a historical control group. Baseline demographics were similar between groups with the exception of lower prevalence of chronic hypertension in the postintervention cohort (23.1% vs 32.1%, P=.005). The primary outcome occurred in 2.8% of patients in the postintervention group and in 11.0% of patients in the historical control group (adjusted odds ratio [aOR] 0.24, 95% CI 0.12–0.49, P<.001). A matched propensity score analysis controlling for chronic hypertension similarly demonstrated a significant reduction in the incidence of the primary outcome. Of the 255 patients (65.4%) who were compliant with outpatient remote BP monitoring, 53 (20.8%) had medication adjustments made per protocol at a median of 6 days (interquartile range 5–8 days) from delivery. Non-Hispanic Black race (aOR 3.42, 95% CI 1.68–6.97), chronic hypertension (aOR 2.09, 95% CI 1.13–3.89), having private insurance (aOR 3.04, 95% CI 1.06–8.72), and discharge on antihypertensive medications (aOR 2.39, 95% CI 1.33–4.30) were associated with requiring outpatient adjustments. CONCLUSION: A standardized clinical assessment and management plan significantly reduced postpartum readmissions and ED visits for patients with hypertension. Close outpatient follow-up to ensure appropriate medication titration after discharge may be especially important in groups at high risk for readmission.

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Section: Resultsmentioning

confidence: 99%

mentioning

confidence: 99%

Standardized Clinical Assessment and Management Plan to Reduce Readmissions for Postpartum Hypertension

Mei

Corry-Saavedra

Nguyen

et al. 2023

Obstetrics &Amp; Gynecology

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“…A large randomized controlled trial of patients with pregnancies at risk for pre-eclampsia (n=1176), including a minority with antiphospholipid syndrome, found a significant decrease in the rate of preterm pre-eclampsia with low dose aspirin at a dose of 150 mg daily started at 11-14 weeks’ gestation 225. Various professional organizations recommend aspirin doses of 75 to 150 mg daily beginning > 12 weeks’ gestation,226227228229230 and ideally by 16227 to 20226 weeks’ gestation to reduce the rate of pre-eclampsia in at risk patients. The optimal low dose aspirin dose is uncertain because dose comparison trials are lacking.…”

Section: Management Of Obstetric Antiphospholipid Syndromementioning

confidence: 99%

Antiphospholipid syndrome: advances in diagnosis, pathogenesis, and management

Knight

Branch

Ortel

2023

BMJ

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Antiphospholipid syndrome (APS) is a thrombo-inflammatory disease propelled by circulating autoantibodies that recognize cell surface phospholipids and phospholipid binding proteins. The result is an increased risk of thrombotic events, pregnancy morbidity, and various other autoimmune and inflammatory complications. Although antiphospholipid syndrome was first recognized in patients with lupus, the stand alone presentation of antiphospholipid syndrome is at least equally common. Overall, the diagnosis appears to affect at least one in 2000 people. Studies of antiphospholipid syndrome pathogenesis have long focused on logical candidates such as coagulation factors, endothelial cells, and platelets. Recent work has shed light on additional potential therapeutic targets within the innate immune system, including the complement system and neutrophil extracellular traps. Vitamin K antagonists remain the mainstay of treatment for most patients with thrombotic antiphospholipid syndrome and, based on current data, appear superior to the more targeted direct oral anticoagulants. The potential role of immunomodulatory treatments in antiphospholipid syndrome management is receiving increased attention. As for many systemic autoimmune diseases, the most important future direction is to more precisely identify mechanistic drivers of disease heterogeneity in pursuit of unlocking personalized and proactive treatments for patients.

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“…The future of preeclampsia screening and prevention should be focused on precision medicine to provide tailored and effective treatment strategies. 18 Lastly, socioeconomic barriers to care need to be explored. Obstetricians should consider multimodal care implementation to include midwives, nurses, emergency physicians, and community-based programs to increase care to all pregnant persons.…”

Section: Jama Network Open | Editorialmentioning

confidence: 99%

“…New technologies, including machine learning, as well as omics data, including genomics, transcriptomics, proteomics, and metabolomics, have been increasing understanding of preeclampsia mechanisms. The future of preeclampsia screening and prevention should be focused on precision medicine to provide tailored and effective treatment strategies . Lastly, socioeconomic barriers to care need to be explored.…”

Section: Indicated Rather Than Routine Screening For Proteinuriamentioning

confidence: 99%

Early Identification of Individuals at Risk for Hypertensive Disorders of Pregnancy

Santos,

Schenone,

Garovic

2023

JAMA Netw Open

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Hypertensive disorders of pregnancy (HDP) are a spectrum of diseases encompassing chronic hypertension, diagnosed prior to 20 weeks' gestation; gestational hypertension, diagnosed after 20 weeks' gestation; and preeclampsia, which, in addition to gestational hypertension, is characterized by systemic features and often proteinuria. 1 The prevalence of HDP has been increasing, with HDP reported in 15.9% of all delivery-associated hospitalizations in 2019, compared with 13.3% in 2017. 2 HDP are associated with severe maternal complications, such as heart attack and stroke, and among the leading causes of maternal mortality in the United States. 2 Non-Hispanic American Indian or Alaskan Native and non-Hispanic Black populations bear a disproportionate amount of disease burden, as do individuals in the lowest median household income quartile or delivering in the South or Midwest Census regions. 2 Since there is no cure for HDP, current strategies have focused on screening and prompt diagnosis to enable surveillance and timely delivery in an effort to avoid complications. 1 In 2017, United States Preventive Services Task Force (USPSTF) recommended screening for preeclampsia with blood pressure (BP) measurements throughout pregnancy. 3 The updated 2023 USPSTF recommendations 4,5 expand their focus from screening for preeclampsia, to screening for the entire HDP spectrum of diseases (B recommendation), since all can be effectively screened with BP measurements and all lead to pregnancy-associated morbidity. Since the benefit of screening for elevated BP during pregnancy has been previously established, the USPSTF critically reviewed the evidence for varied screening approaches. 4,5 Home BP MeasurementThe Blood Pressure Monitoring in High Risk Pregnancy to Improve the Detection and Monitoring of Hypertension trial, 6 a large, randomized clinical trial, evaluated the use of home BP monitoring, in addition to routine prenatal care. The addition of home BP measurements did not change the frequency of HDP diagnosis, the number of days needed to detect HDP, the frequency of preeclampsia diagnosis, or perinatal outcomes. 6 Reduced Prenatal Screening Visits for Patients Deemed Low RiskUSPSTF assessed 3 randomized clinical trials on reduced prenatal screening visits for patients considered to be a low risk, such as a 1996 study by McDuffie et al. 7 These studies did not find any differences in perinatal outcomes. Specifically, preterm delivery, incidence of preeclampsia, or Cesarean delivery were not different between the reduced visit and control groups. Indicated Rather Than Routine Screening for ProteinuriaA nonrandomized study by Rhode et al 8 used historical controls to assess indicated urine screening for conditions in pregnancy, such as urinary tract infection. Rhode et al 8 found no difference in the proportion of individuals diagnosed with HDP. 8 Consequently, the USPSTF found inadequate evidence that this approach is more accurate than regular blood pressure measurement, given the lack of demonstrated benefit. 4,5...

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Preeclampsia: a report and recommendations of the workshop of the Society for Maternal-Fetal Medicine and the Preeclampsia Foundation

Cited by 11 publications

References 169 publications

Standardized Clinical Assessment and Management Plan to Reduce Readmissions for Postpartum Hypertension

Standardized Clinical Assessment and Management Plan to Reduce Readmissions for Postpartum Hypertension

Antiphospholipid syndrome: advances in diagnosis, pathogenesis, and management

Early Identification of Individuals at Risk for Hypertensive Disorders of Pregnancy

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