The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care

Abstract

Purpose of Review The “fourth trimester” concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women’s cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester. Recent Findings A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness. Summary Development of a comprehensive postpartum care plan with careful consideration of each patient’s risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.

Perceptions about future health trajectories among women at risk for developing cardiometabolic disease: A qualitative study

“…Although not routine in the United States, fourth-trimester care has been identified as an ideal opportunity for comprehensive cardiometabolic evaluation and handoff of care from obstetrics to primary and specialty providers. 25 In addition to a six-fold increase in risk for developing T2DM, having a HDP increases a woman’s risk for cardiovascular mortality by 40%, contributing to the United States’ already significant burden of pregnancy-related morbidity or mortality. 26 Such care could provide a means of supporting long-term health by formalizing the follow-up plan for pregnancy-associated cardiometabolic risk.…”

“…Optimally, fourth-trimester care would be home-based and would leverage telehealth so as to minimize common barriers to postpartum care. Additionally, this care would include tailored guidance on postpartum health behaviors 25 and could serve to educate women on the associations between pregnancy outcomes and their long-term health risks.…”

Perceptions about health-risk awareness and lifestyle change among women at risk for developing cardiometabolic disease: a qualitative study

“…Fourth-trimester care is defined as postpartum maternal healthcare that occurs during the year following pregnancy. Although not routine in the United States, fourth-trimester care has been identified as an ideal opportunity for comprehensive cardiometabolic evaluation and handoff of care from obstetrics to primary and specialty providers [34]. In addition to a sixfold increase in risk for developing T2DM, having an HDP increases a woman's risk for cardiovascular mortality by 40%, contributing to the United States' already significant burden of pregnancy-related morbidity or mortality [35].…”

Cardiovascular disease prevention in women – the current state in 2023

“…The recognition of APOs is thus instrumental in determining a patient-centered approach to assessing CVD risk as evidenced by the recommendations of both the American College of Obstetrics and Gynecology and the AHA for rigorous cardiovascular risk screening among women with a history of APOs [14 ▪ ,15]. The ‘fourth trimester’ is a particularly critical time of transition from obstetric care to primary care (or cardiology if needed) to further optimize cardiovascular health inter-pregnancy and beyond; it is imperative to identify and treat risk factors after an APO for long-term CVD prevention [32].…”