Evaluation of Postpartum Counseling on Future Health Risks Associated with Hypertensive Disorders of Pregnancy

Abstract

Background: The American College of Obstetricians and Gynecologists and the American Heart Association recommend that women with hypertensive disorders of pregnancy be counseled on lifelong cardiovascular risks and transitioned to primary care for ongoing screening and management. Objective: To assess frequency and content of postpartum counseling regarding cardiovascular risk and follow-up among women with hypertensive disorders of pregnancy. Study Design: A secondary analysis of a randomized trial of women with hypertensive disorders of pregnancy, excluding chronic hypertension, performed at a single tertiary care academic hospital. We abstracted documented counseling on hypertensive disorders from the discharge summary and postpartum visit note in the electronic medical record. We defined counseling as documentation of any one of the following: 1) recommending aspirin in a future pregnancy, 2) follow-up with primary care, or 3) lifelong risk of cardiovascular disease. We used logistic regression models to estimate adjusted odds for receiving counseling. Results: Seventy-four women enrolled in the study. A hypertensive diagnosis was documented for 71 women (96.0%) in the discharge summary, but only 11 (14.9%) had any documented counseling in the discharge summary or postpartum visit note. Of the 11 women counseled, 5 (6.7%) were counseled on taking aspirin in a future pregnancy, 5 (6.7%) were counseled on follow-up with primary care, and only 3 (4.1%) were counseled on the lifelong cardiovascular risk associated with hypertension in pregnancy. Two women (2.7%) were counseled on follow-up with primary care and lifelong cardiovascular risk. There were no participants counseled on all three components. Later gestational age at delivery was associated with lower odds of counseling (adjusted OR 0.49, 95% CI 0.27-0.89). Conclusion: Despite consistent evidence on long-term risks of hypertensive disorders of pregnancy, counseling about those risks is suboptimal. Improved communication of risks is the first step towards improving maternal health in the “fourth trimester” and beyond.

Postpartum counseling in women with hypertensive disorders of pregnancy

“…12 Among women with HDP excluding all women with chronic hypertension, less than 10% of women were counseled on transitions of care, CVD risk, and aspirin in future pregnancies. 13 We found that the only patient-level characteristic associated with documented counseling was black race. There are some data that non-white women are less likely to perceive CVD as a significant personal health risk, although the gap in awareness has decreased over time.…”

“…10,11 Although the postpartum period is a critical time to promote women's cardiovascular health, limited data suggest that counseling is not routine. 12,13 We hypothesized that most women with HDP do not receive adequate counseling about the long-term sequelae of these disorders in the postpartum period. We measured the documentation of counseling on factors that would have a direct impact on future maternal health including future risks of CVD, transition to continuity providers including primary care providers (PCPs) and cardiologists, and recommendation for aspirin use in subsequent pregnancies.…”

Electronic Reminder to Transition Care After Hypertensive Disorders of Pregnancy

“…20 In prior studies using medical record review for patients with hypertensive disorders of pregnancy, few had documented counseling on transitions of care to primary care or based on CVD risk. 15,21 Current recommendations for care after hypertensive disorders of pregnancy are limited in scope or detail, 6,7 focus on hospital discharge as the time to provide counseling, 16 and do not address how to successfully transition patients to preventive care clinicians. Uncertainty about how to counsel and screen for CVD risk may affect the implementation of postpartum counseling on hypertensive disorders of pregnancy.…”

“…20 In prior studies using medical record review for patients with hypertensive disorders of pregnancy, few had documented counseling on transitions of care to primary care or based on CVD risk. 15,21…”