Postpartum counseling in women with hypertensive disorders of pregnancy

Abstract

BACKGROUND: Hypertensive disorders of pregnancy are associated with increased cardiovascular disease risk across the lifespan. The American College of Obstetricians and Gynecologists and the American Heart Association emphasize the postpartum period as an important opportunity to identify and intervene women at high risk of future cardiovascular disease. OBJECTIVE: This study aimed to determine the proportion of women with documented counseling on risks and transitions of care after hypertensive disorders of pregnancy at the postpartum visit. STUDY DESIGN: This was a retrospective longitudinal descriptive study of women with hypertensive disorders of pregnancy who were enrolled in a text-based blood pressure program from September 2018 to February 2019. We abstracted counseling in the discharge summary and postpartum note from the electronic medical record. The primary outcome was counseling at the postpartum visit defined as documentation of (1) follow-up with primary care or cardiology, (2) risk of cardiovascular disease, or (3) recommendation for aspirin in a future pregnancy. We assessed demographic and clinical factors that may influence counseling through multivariable logistic regression. We also compared the proportion of women counseled on hypertensive disorders of pregnancy vs contraception and glucose tolerance tests at the postpartum visit.RESULTS: Of 320 eligible women, most women had gestational hypertension or preeclampsia without severe features (64%). Postpartum visits were scheduled in our hospital system for 284 women, of whom 253 attended (89%). Documented counseling occurred for 62 women (25%). Counseling on follow-up with primary care or cardiology, cardiovascular disease risk, and aspirin in future pregnancies was documented for 51 (20%), 15 (6%), and 1 (0.4%), respectively. Only 1 woman had documented counseling on all 3 components. In multivariable analysis, black race remained an independent factor that increased the likelihood of counseling on hypertensive disorders of pregnancy (adjusted odds ratio, 2.77; 95% confidence interval, 1.32e5.83). Women were significantly less likely to be counseled on hypertensive disorders of pregnancy than on contraceptives (99%, P<.001) or glucose tolerance testing after gestational diabetes mellitus (79%, P<.001). CONCLUSION: Postpartum counseling on hypertensive disorders of pregnancy merits urgent improvement efforts among obstetrical care providers.

Trends in Cardiovascular Health Counseling Among Postpartum Individuals

“…Prevalence of self-reported CVH counseling in 2020 was lowest among individuals with hypertensive disorders of pregnancy (55%), which is an APO that is a recognized risk-enhancing factor for CVD and associated with a 2-fold higher lifetime risk of heart failure and ischemic heart disease . Although previous data regarding CVH counseling after APOs are limited, one small study of 350 individuals with hypertensive disorders of pregnancy at a single institution revealed that only 6% had counseling on CVD risk documented in the medical record at the postpartum visit . It is possible that CVD counseling may be underdocumented in the medical record and prevalence of CVH counseling in the present analysis may have been higher due to use of self-report.…”

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…”

“…The sample size was calculated on the basis of 21% of patients having documented counseling on transitions of care. 15 To reach a clinically meaningful improvement in documented counseling to 40%, we estimated that a sample size of 94 per group (n5188) was sufficient, assuming 80% power using a two-tailed test and a type I error rate of 0.05. Assuming that 15% would not attend a postpartum visit, we increased the sample size to 222.…”

Improving Cardiovascular Follow-Up after Diagnosis of a Hypertensive Disorder of Pregnancy using the Electronic Health Record

“…Knowledge about the association between cardiovascular risk after preeclampsia is limited among women and providers, which could lead to lack of counseling and follow-up (Dijkhuis et al, 2020). Triebwasser et al (2021) found patient counseling after HDP on cardiovascular risk and the importance of follow-up was limited at the postpartum visit, with only about 25% of women in their study receiving appropriate counseling at the postpartum visit. It is important for nurses to create processes to standardize distribution of education on recommendations about cardiovascular risk reduction and follow-up after HDP.…”