HHS Public Access Author manuscript Author Manuscript
J Perinatol. Author manuscript; available in PMC 2017 June 22. Published in final edited form as: J Perinatol. 2016 December ; 36(12): 1079–1082. doi:10.1038/jp.2016.137.
Factors associated with postpartum follow-up and persistent hypertension among women with severe preeclampsia LD Levine1, C Nkonde-Price2, M Limaye3, and SK Srinivas1 1Maternal
and Child Health Research Program, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
Author Manuscript
2Department
of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
3Department
of Obstetrics & Gynecology, Women and Infants Hospital, Alpert Medical School at Brown University, Providence, RI, USA
Abstract Objective—To determine factors associated with lower 6-week postpartum follow-up rates and persistent hypertension among women with preeclampsia with severe features (PEC-S). Study Design—Planned secondary analysis of a retrospective cohort study of women with PECS. Outcomes were (1) attendance at the 6-week postpartum visit and (2) persistent hypertension.
Author Manuscript
Results—One hundred ninety-three women were in the final cohort. The 6-week follow-up rate was 52.3%. Factors associated with lower follow-up were African-American race (OR 0.37 (0.18– 0.77)) and < 5 prenatal visits (OR 0.44 (0.20–0.97)). Women with diabetes and women with a cesarean had higher follow-up (OR 4.00 (1.09–14.66) and 2.61 (1.40–4.88), respectively). Among those with 6-week follow-up, 21% had persistent hypertension. Obese women, women diagnosed with PEC-S by severe range blood pressure (BP) and women discharged home on BP medication were more likely to have persistent hypertension (OR 3.50 7 (1.06–11.58), 3.58 (1.11-11.54) and 3.04 (1.12–8.23), respectively). Conclusion—We identified a subgroup of women at higher risk for poor postpartum follow-up and those at risk for persistent hypertension.
Introduction Author Manuscript
The postpartum visit is an important and influential visit for women after childbirth. Specifically for women with severe preeclampsia, it is a critical time point that allows physicians to assess blood pressure status, and counsel women on the implications of preeclampsia for future pregnancies and on the association between preeclampsia and cardiovascular disease. The American College of Obstetricians and Gynecologists1 recommends counseling women with severe preeclampsia before a subsequent pregnancy Correspondence: Dr LD Levine, Maternal and Child Health Research Program, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2000 Courtyard, Philadelphia, PA 19104, USA. [email protected]. Conflict of Interest: The authors declare no conflict of interest.
Levine et al.
Page 2
Author Manuscript
and suggests that an ideal time for this is at their postpartum visit. The association between preeclampsia and long-term cardiovascular morbidity is well established,2–5 with the American Heart Association recently concluding that pre-eclampsia is a potent cardiovascular risk factor, as strong as diabetes.6,7 One proposed risk factor for cardiovascular morbidity is the persistence of hypertension in the postpartum period.8,9 Identifying women with persistent hypertension can ensure appropriate entry into care and enable possible treatment that may aid in preventing some of the long-term cardiovascular morbidity that is seen for women with preeclampsia. Close postpartum follow-up is critical to effectively manage and potentially modify a woman's long-term risk.
Author Manuscript
Therefore, the postpartum period is a critical time for obstetrician gynecologists to ensure that women with a history of preeclampsia are transitioned to a primary care provider to help with both short-term and long-term follow-up. Ongoing long-term follow-up is especially important since women with a history of preeclampsia are at high risk for future cardiac disease. Unfortunately, postpartum follow-up rates are notoriously poor, reported to be 20– 60%.8,10,11 It is therefore of utmost importance to understand the demographic and clinical factors that are associated with a likelihood of following up at a postpartum visit for women with a history of preeclampsia in order to target these high-risk women and ensure appropriate and important follow-up care. Therefore, there were two objectives to our study. The first objective was to determine the factors that were associated with lower postpartum follow-up rates among women with PEC-S. The second objective was to evaluate factors that were associated with persistence of hypertension among women with PEC-S at 6 weeks postpartum.
Author Manuscript
Methods This was a planned secondary analysis of a retrospective cohort of women withPEC-S. The parent study included all women with PEC-S who were carrying a singleton gestation, were diagnosed with PEC-S prior to active labor, were ≥ 34 weeks gestation and who delivered between July 2011 and February 2013 at the Hospital of the University of Pennsylvania.12 Approval was obtained from the Institutional Review Board prior to the study. The first objective was to determine demographic and clinical factors that were associated with lower postpartum follow-up rates among women with PEC-S. For this objective, our primary outcome was documented attendance at the 6-week postpartum visit.
Author Manuscript
The second objective was to evaluate demographic and clinical factors that were associated with persistence of hypertension among women with PEC-S who attended their 6-week postpartum visit. For this objective, our primary outcome was persistence of hypertension at 6 weeks postpartum. This was defined as a systolic blood pressure ≥ 140 mm Hg, a diastolic blood pressure ≥ 90 mm Hg or the need for antihypertensive agents in someone previously not on them. Preeclampsia with severe features was defined by current American College of Obstetricians and Gynecologists guidelines.1 Briefly, preeclampsia with severe features is diagnosed in the following settings: (1) severe range blood pressures—systolic blood pressure of ≥ 160 mm
J Perinatol. Author manuscript; available in PMC 2017 June 22.
Levine et al.
Page 3
Author Manuscript
Hg or diastolic blood pressure of ≥ 110 mm Hg with or without other laboratory findings and/or clinical symptoms, or (2) mild range blood pressure— systolic blood pressure of ≥ 140 mm Hg or diastolic blood pressure of ≥ 90 mm Hg in the setting of any of the following: thrombocytopenia (< 100 000/μl), impaired liver function tests (aspartate transaminase or alanine transaminase twice normal), renal insufficiency (creatinine > 1.1 mg/dl or doubling of the baseline creatinine in the absence of renal disease), persistent right upper quadrant pain, pulmonary edema, new-onset cerebral or visual disturbances. Data were abstracted from the electronic medical record and included demographic information, medical and obstetrical history, as well as their labor, delivery and postpartum information.
Author Manuscript
There was a fixed sample size (n = 193) based on the number of women included in the parent study. Based on an assumption of a 50% postpartum show rate, we would have more than 80% power to see the following differences: for exposure variables with a prevalence of 15%, we could detect a 2.25-fold difference; 20% prevalence, a 2-fold difference; 40% prevalence, a 1.6-fold difference; and 60% prevalence, a 1.35-fold difference. Chi square analyses and Fisher's exact tests were used to compare categorical variables. Logistic regression was used to calculate unadjusted odds ratios. Data were analyzed using Stata version 12.0 (College Station, TX, USA). A two-sided P-value of < 0.05 was used for statistical significance.
Results Author Manuscript
There were 347 women identified as having preeclampsia with severe features in the electronic medical record during the study period; 193 women were included in the parent study12 and in our current analyses. Demographic information for the entire cohort is shown in Table 1. More than 75% of our patient population was African American and just over half were nulliparous and obese.
Author Manuscript
The overall follow-up rate at the 6-week postpartum visit was 52.3% (n = 101). Table 2 shows the odds of postpartum follow-up among various demographic and clinical characteristics. Women younger than 30 years old were less likely to follow up as compared to women ≥ 30 (48.2% vs 63.0%, OR 0.55 (0.29–1.04), P = 0.067), although this was not significant. African-American women were less likely to follow up than non-AfricanAmerican women (47.0% vs 70.5%, OR 0.37 (0.18–0.77), P = 0.007). Women with < 5 prenatal visits were also less likely to follow up as compared to women with ≥ 5 prenatal visits (37.5% vs 57.42%, OR 0.44 (0.20–0.97), P = 0.043). Women with diabetes were more likely to follow up as compared to non-diabetic women (80.0% vs 50.0%, OR 4.00 (1.09– 14.66), P= 0.036), as were women delivered by cesarean delivery compared to those with a vaginal delivery (67.7% vs 44.5%, OR 2.61 (1.40–4.88), P = 0.003). Of note, three out of the six patients with chronic hypertension presented for their follow-up visit. Given the possibility of chronic hypertension confounding our results, we analyzed the data excluding these three women and our results were unchanged.
J Perinatol. Author manuscript; available in PMC 2017 June 22.
Levine et al.
Page 4
Author Manuscript Author Manuscript
Among the 101 women who presented for their postpartum visit, persistent hypertension occurred in 22 (21%). Of these 22 women, 15 (68.2%) met the criteria for persistent hypertension based on persistent BP ≥ 140/90, regardless of being on an antihypertensive agent, with 7 (31.8%) women being normotensive on an antihypertensive agent. Table 3 shows the odds of persistence hypertension at the postpartum visit for various demographic and clinical characteristics. A higher odds of persistent disease was noted in morbidly obese women compared to non-morbidly obese women (42.9% vs 17.7%, OR 3.50 (1.06– 11.58), P = 0.040). Women diagnosed with PEC-S based on severe range blood pressure criteria (with or without laboratory changes and/or clinical symptoms) also had a higher odds of persistent hypertension compared to women diagnosed with PEC-S based on mild range blood pressures with abnormal laboratory results or clinical symptoms (29.0% vs 10.3%, OR 3.58 (1.11–11.54), P =0.033). Additionally, women who were discharged home on a blood pressure medication were also more likely to have persistent hypertension (37.0% vs 16.2%, OR 3.04 (1.12–8.23), P = 0.029). Although not statistically significant, African-American women (African American, 25.7% vs non-African American, 12.9%, P =0.15) and women readmitted to the hospital in the postpartum period (readmitted, 66.7% vs not readmitted, 20.4%, P = 0.056) have an association with persistent hypertension.
Discussion
Author Manuscript
This study investigated both demographic and clinical factors that are associated with lower postpartum follow-up rates for women ≥ 34 weeks with PEC-S and factors that are associated with persistence of hypertensive disease among these women. While only half of the women in this study had a postpartum follow-up visit (52%), this rate is on the higher end of what is reported in the literature.8,10,11 We identified a subgroup of women who are at higher risk of not returning for their postpartum appointment. Specifically, younger AfricanAmerican women with fewer prenatal visits were less likely to follow up for their visit and women with diabetes in pregnancy and a cesarean delivery were more likely to follow up.
Author Manuscript
Additionally, 21% of women in our study were found to have persistent hypertensive disease at 6 weeks postpartum. This rate is consistent with prior literature evaluating resolution of hypertension in the immediate postpartum period.8,13 We identified morbidly obese women, women diagnosed with PEC-S based on blood pressure criteria and women who were discharged home on a blood pressure medication as those at significantly higher risk of persistent hypertensive disease. It is important to identify these at-risk women during their pregnancy to counsel them regarding their increased lifetime risk of cardiac disease and stress the importance of follow-up. In the survey study by Brown et al.,14 only 10% of women with severe preeclampsia understood their associated lifetime risk. It is plausible that improved prenatal counseling or counseling in the immediate postpartum period would lead to an increased understanding of their risk and enable improvements in postpartum followup rates. An important strength of this study is that, at our institution, less than 10% of women receive prenatal and postpartum care outside of our hospital system. Therefore, follow-up visits and records are available for the majority of patients who were in this study, limiting the number of women with follow-up at another institution. Additionally, to our knowledge,
J Perinatol. Author manuscript; available in PMC 2017 June 22.
Levine et al.
Page 5
Author Manuscript Author Manuscript
there are no known provider differences or postpartum follow-up reminders that would differentially affect a subgroup of women within this study group, thereby biasing our results. All women are encouraged to follow up for their postpartum visit and receive a telephone reminder about scheduled appointments. Limitations include the fixed sample size from the parent study, which makes us underpowered to see potentially meaningful differences in the clinical and demographic factors associated with our outcomes. Additionally, persistent hypertension rates were only known for the women with follow-up and therefore our rate of 18% could be overestimated if only the highest-risk women presented, or could be underestimated if the highest-risk women did not present for their follow-up visit. The high rate of African-American women receiving care at one urban institution may make these results less generalizable; however, it is also important to focus on this specific group of women known to be at the highest risk for long-term cardiovascular outcomes.7 Lastly, we used the need for antihypertensive agents in someone previously not on them as a definition for persistent hypertension. There were seven women who were normotensive on their antihypertensive agents at the 6-week visit. It is plausible that some of these women were kept on their medication without a trial off of medication and may have, in fact, been normotensive. This would have inappropriately classified them with persistent hypertension and biased our results. The postpartum period is a unique opportunity for healthcare providers to educate women about their lifetime cardiovascular risk after preeclampsia and possibly alter modifiable risk factors. It is important to continue to identify women at highest risk for poor follow-up and persistent hypertensive disease. Future research should be focused on strategies to improve postpartum follow-up, especially among the women identified in our study to be at high risk of not attending their visit and at high risk of persistent hypertension.
Author Manuscript
Acknowledgments This study was funded in part by a career development award in Women's Reproductive Health Research: K12HD001265-14.
References
Author Manuscript
1. American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy: report from the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013; 122:1122–1131. [PubMed: 24150027] 2. Andersgaard AB, Acharya G, Mathiesen EB, Johnson SH, Straume B, Oian P. Recurrence and longterm maternal health risks of hypertensive disorders of pregnancy: a population-based study. Am J Obstet Gynecol. 2012; 206(143):e1–e8. 3. Wilson BJ, Watson MS, Prescott GJ, Sunderland S, Campbell DM, Hannaford P, Smith WC. Hypertensive disease of pregnancy and risk of hypertension and stroke in later life: results from cohort study. BMJ. 2003; 326:845. [PubMed: 12702615] 4. Bellamy L, Cases JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. 2007; 335:974. [PubMed: 17975258] 5. McDonald SD, Malinowski A, Zhou Q, Yusuf S, Devereaux PJ. Cardiovascular sequelae of preeclampsia/eclampsia: a systematic review and meta-analyses. Am Heart J. 2008; 156:918–930. [PubMed: 19061708]
J Perinatol. Author manuscript; available in PMC 2017 June 22.
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6. NHLBI Workshop. [15 November 2015] Bridging preeclampsia and future cardiovascular disease. Executive summary. 2010. Available at: http://www.nhlbi.nih.gov/meetings/workshops/bridgingpe.htm 7. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics – 2015 update: a report from the American Heart Association. Circulation. 2015; 131:e29–322. [PubMed: 25520374] 8. Berks D, Steegers EP, Molas M, Visser W. Resolution of hypertension and proteinuria after preeclampsia. Obstet Gynecol. 2009; 114:1307–1314. [PubMed: 19935034] 9. Edlow AG, Srinivas SK, Elovitz MA. Investigating the risk of hypertension shortly after pregnancies complicated by preeclampsia. Am J Obstet Gynecol. 2009; 200:e60–e62. [PubMed: 19111719] 10. Traylor J, Chandrasekaran S, Limaye M, Srinivas S, Durnwald CP. Risk perception of future cardiovascular disease in women diagnosed with a hypertensive disorder of pregnancy. J Matern Fetal Neonatal Med. 2015; 15:1–6. 11. Levine LD, Chang J, Merkatz IR, Bernstein PS. Enhanced physician prompts in prenatal electronic medical records impact documentation on smoking cessation. Open J Obstet Gynecol. 2013; 3:717–721. [PubMed: 24653945] 12. Levine LD, Elovitz MA, Limaye M, Sammel MD, Srinivas SK. Induction, labor length and mode of delivery: the impact on preeclampsia related adverse maternal outcomes. J Perinatol. 2016; epub ahead of print. doi: 10.1038/jp.2016.84 13. Goel A, Maski MR, Bajracharya S, Wenger JB, Zhang D, Salahuddin S, et al. Epidemiology and mechanisms of De Novo and persistent hypertension in the postpartum period. Circulation. 2015; 132(18):1726–1733. [PubMed: 26416810] 14. Brown MC, Bell R, Collins C, Waring G, Robson SC, Waugh J, et al. Women's perception of future risk following pregnancies complicated by preeclampsia. Hypertens Pregnancy. 2013; 32:60–73. [PubMed: 22957520]
Author Manuscript Author Manuscript J Perinatol. Author manuscript; available in PMC 2017 June 22.
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Table 1
Demographic information for the entire cohort*
Author Manuscript
Characteristic
Cohort (n=193)
Age (years)a
25.0 (21.2–30.4)
BMI (kg/m2)
J Perinatol. Author manuscript; available in PMC 2017 June 22. Published in final edited form as: J Perinatol. 2016 December ; 36(12): 1079–1082. doi:10.1038/jp.2016.137.
Factors associated with postpartum follow-up and persistent hypertension among women with severe preeclampsia LD Levine1, C Nkonde-Price2, M Limaye3, and SK Srinivas1 1Maternal
and Child Health Research Program, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
Author Manuscript
2Department
of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
3Department
of Obstetrics & Gynecology, Women and Infants Hospital, Alpert Medical School at Brown University, Providence, RI, USA
Abstract Objective—To determine factors associated with lower 6-week postpartum follow-up rates and persistent hypertension among women with preeclampsia with severe features (PEC-S). Study Design—Planned secondary analysis of a retrospective cohort study of women with PECS. Outcomes were (1) attendance at the 6-week postpartum visit and (2) persistent hypertension.
Author Manuscript
Results—One hundred ninety-three women were in the final cohort. The 6-week follow-up rate was 52.3%. Factors associated with lower follow-up were African-American race (OR 0.37 (0.18– 0.77)) and < 5 prenatal visits (OR 0.44 (0.20–0.97)). Women with diabetes and women with a cesarean had higher follow-up (OR 4.00 (1.09–14.66) and 2.61 (1.40–4.88), respectively). Among those with 6-week follow-up, 21% had persistent hypertension. Obese women, women diagnosed with PEC-S by severe range blood pressure (BP) and women discharged home on BP medication were more likely to have persistent hypertension (OR 3.50 7 (1.06–11.58), 3.58 (1.11-11.54) and 3.04 (1.12–8.23), respectively). Conclusion—We identified a subgroup of women at higher risk for poor postpartum follow-up and those at risk for persistent hypertension.
Introduction Author Manuscript
The postpartum visit is an important and influential visit for women after childbirth. Specifically for women with severe preeclampsia, it is a critical time point that allows physicians to assess blood pressure status, and counsel women on the implications of preeclampsia for future pregnancies and on the association between preeclampsia and cardiovascular disease. The American College of Obstetricians and Gynecologists1 recommends counseling women with severe preeclampsia before a subsequent pregnancy Correspondence: Dr LD Levine, Maternal and Child Health Research Program, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2000 Courtyard, Philadelphia, PA 19104, USA. [email protected]. Conflict of Interest: The authors declare no conflict of interest.
Levine et al.
Page 2
Author Manuscript
and suggests that an ideal time for this is at their postpartum visit. The association between preeclampsia and long-term cardiovascular morbidity is well established,2–5 with the American Heart Association recently concluding that pre-eclampsia is a potent cardiovascular risk factor, as strong as diabetes.6,7 One proposed risk factor for cardiovascular morbidity is the persistence of hypertension in the postpartum period.8,9 Identifying women with persistent hypertension can ensure appropriate entry into care and enable possible treatment that may aid in preventing some of the long-term cardiovascular morbidity that is seen for women with preeclampsia. Close postpartum follow-up is critical to effectively manage and potentially modify a woman's long-term risk.
Author Manuscript
Therefore, the postpartum period is a critical time for obstetrician gynecologists to ensure that women with a history of preeclampsia are transitioned to a primary care provider to help with both short-term and long-term follow-up. Ongoing long-term follow-up is especially important since women with a history of preeclampsia are at high risk for future cardiac disease. Unfortunately, postpartum follow-up rates are notoriously poor, reported to be 20– 60%.8,10,11 It is therefore of utmost importance to understand the demographic and clinical factors that are associated with a likelihood of following up at a postpartum visit for women with a history of preeclampsia in order to target these high-risk women and ensure appropriate and important follow-up care. Therefore, there were two objectives to our study. The first objective was to determine the factors that were associated with lower postpartum follow-up rates among women with PEC-S. The second objective was to evaluate factors that were associated with persistence of hypertension among women with PEC-S at 6 weeks postpartum.
Author Manuscript
Methods This was a planned secondary analysis of a retrospective cohort of women withPEC-S. The parent study included all women with PEC-S who were carrying a singleton gestation, were diagnosed with PEC-S prior to active labor, were ≥ 34 weeks gestation and who delivered between July 2011 and February 2013 at the Hospital of the University of Pennsylvania.12 Approval was obtained from the Institutional Review Board prior to the study. The first objective was to determine demographic and clinical factors that were associated with lower postpartum follow-up rates among women with PEC-S. For this objective, our primary outcome was documented attendance at the 6-week postpartum visit.
Author Manuscript
The second objective was to evaluate demographic and clinical factors that were associated with persistence of hypertension among women with PEC-S who attended their 6-week postpartum visit. For this objective, our primary outcome was persistence of hypertension at 6 weeks postpartum. This was defined as a systolic blood pressure ≥ 140 mm Hg, a diastolic blood pressure ≥ 90 mm Hg or the need for antihypertensive agents in someone previously not on them. Preeclampsia with severe features was defined by current American College of Obstetricians and Gynecologists guidelines.1 Briefly, preeclampsia with severe features is diagnosed in the following settings: (1) severe range blood pressures—systolic blood pressure of ≥ 160 mm
J Perinatol. Author manuscript; available in PMC 2017 June 22.
Levine et al.
Page 3
Author Manuscript
Hg or diastolic blood pressure of ≥ 110 mm Hg with or without other laboratory findings and/or clinical symptoms, or (2) mild range blood pressure— systolic blood pressure of ≥ 140 mm Hg or diastolic blood pressure of ≥ 90 mm Hg in the setting of any of the following: thrombocytopenia (< 100 000/μl), impaired liver function tests (aspartate transaminase or alanine transaminase twice normal), renal insufficiency (creatinine > 1.1 mg/dl or doubling of the baseline creatinine in the absence of renal disease), persistent right upper quadrant pain, pulmonary edema, new-onset cerebral or visual disturbances. Data were abstracted from the electronic medical record and included demographic information, medical and obstetrical history, as well as their labor, delivery and postpartum information.
Author Manuscript
There was a fixed sample size (n = 193) based on the number of women included in the parent study. Based on an assumption of a 50% postpartum show rate, we would have more than 80% power to see the following differences: for exposure variables with a prevalence of 15%, we could detect a 2.25-fold difference; 20% prevalence, a 2-fold difference; 40% prevalence, a 1.6-fold difference; and 60% prevalence, a 1.35-fold difference. Chi square analyses and Fisher's exact tests were used to compare categorical variables. Logistic regression was used to calculate unadjusted odds ratios. Data were analyzed using Stata version 12.0 (College Station, TX, USA). A two-sided P-value of < 0.05 was used for statistical significance.
Results Author Manuscript
There were 347 women identified as having preeclampsia with severe features in the electronic medical record during the study period; 193 women were included in the parent study12 and in our current analyses. Demographic information for the entire cohort is shown in Table 1. More than 75% of our patient population was African American and just over half were nulliparous and obese.
Author Manuscript
The overall follow-up rate at the 6-week postpartum visit was 52.3% (n = 101). Table 2 shows the odds of postpartum follow-up among various demographic and clinical characteristics. Women younger than 30 years old were less likely to follow up as compared to women ≥ 30 (48.2% vs 63.0%, OR 0.55 (0.29–1.04), P = 0.067), although this was not significant. African-American women were less likely to follow up than non-AfricanAmerican women (47.0% vs 70.5%, OR 0.37 (0.18–0.77), P = 0.007). Women with < 5 prenatal visits were also less likely to follow up as compared to women with ≥ 5 prenatal visits (37.5% vs 57.42%, OR 0.44 (0.20–0.97), P = 0.043). Women with diabetes were more likely to follow up as compared to non-diabetic women (80.0% vs 50.0%, OR 4.00 (1.09– 14.66), P= 0.036), as were women delivered by cesarean delivery compared to those with a vaginal delivery (67.7% vs 44.5%, OR 2.61 (1.40–4.88), P = 0.003). Of note, three out of the six patients with chronic hypertension presented for their follow-up visit. Given the possibility of chronic hypertension confounding our results, we analyzed the data excluding these three women and our results were unchanged.
J Perinatol. Author manuscript; available in PMC 2017 June 22.
Levine et al.
Page 4
Author Manuscript Author Manuscript
Among the 101 women who presented for their postpartum visit, persistent hypertension occurred in 22 (21%). Of these 22 women, 15 (68.2%) met the criteria for persistent hypertension based on persistent BP ≥ 140/90, regardless of being on an antihypertensive agent, with 7 (31.8%) women being normotensive on an antihypertensive agent. Table 3 shows the odds of persistence hypertension at the postpartum visit for various demographic and clinical characteristics. A higher odds of persistent disease was noted in morbidly obese women compared to non-morbidly obese women (42.9% vs 17.7%, OR 3.50 (1.06– 11.58), P = 0.040). Women diagnosed with PEC-S based on severe range blood pressure criteria (with or without laboratory changes and/or clinical symptoms) also had a higher odds of persistent hypertension compared to women diagnosed with PEC-S based on mild range blood pressures with abnormal laboratory results or clinical symptoms (29.0% vs 10.3%, OR 3.58 (1.11–11.54), P =0.033). Additionally, women who were discharged home on a blood pressure medication were also more likely to have persistent hypertension (37.0% vs 16.2%, OR 3.04 (1.12–8.23), P = 0.029). Although not statistically significant, African-American women (African American, 25.7% vs non-African American, 12.9%, P =0.15) and women readmitted to the hospital in the postpartum period (readmitted, 66.7% vs not readmitted, 20.4%, P = 0.056) have an association with persistent hypertension.
Discussion
Author Manuscript
This study investigated both demographic and clinical factors that are associated with lower postpartum follow-up rates for women ≥ 34 weeks with PEC-S and factors that are associated with persistence of hypertensive disease among these women. While only half of the women in this study had a postpartum follow-up visit (52%), this rate is on the higher end of what is reported in the literature.8,10,11 We identified a subgroup of women who are at higher risk of not returning for their postpartum appointment. Specifically, younger AfricanAmerican women with fewer prenatal visits were less likely to follow up for their visit and women with diabetes in pregnancy and a cesarean delivery were more likely to follow up.
Author Manuscript
Additionally, 21% of women in our study were found to have persistent hypertensive disease at 6 weeks postpartum. This rate is consistent with prior literature evaluating resolution of hypertension in the immediate postpartum period.8,13 We identified morbidly obese women, women diagnosed with PEC-S based on blood pressure criteria and women who were discharged home on a blood pressure medication as those at significantly higher risk of persistent hypertensive disease. It is important to identify these at-risk women during their pregnancy to counsel them regarding their increased lifetime risk of cardiac disease and stress the importance of follow-up. In the survey study by Brown et al.,14 only 10% of women with severe preeclampsia understood their associated lifetime risk. It is plausible that improved prenatal counseling or counseling in the immediate postpartum period would lead to an increased understanding of their risk and enable improvements in postpartum followup rates. An important strength of this study is that, at our institution, less than 10% of women receive prenatal and postpartum care outside of our hospital system. Therefore, follow-up visits and records are available for the majority of patients who were in this study, limiting the number of women with follow-up at another institution. Additionally, to our knowledge,
J Perinatol. Author manuscript; available in PMC 2017 June 22.
Levine et al.
Page 5
Author Manuscript Author Manuscript
there are no known provider differences or postpartum follow-up reminders that would differentially affect a subgroup of women within this study group, thereby biasing our results. All women are encouraged to follow up for their postpartum visit and receive a telephone reminder about scheduled appointments. Limitations include the fixed sample size from the parent study, which makes us underpowered to see potentially meaningful differences in the clinical and demographic factors associated with our outcomes. Additionally, persistent hypertension rates were only known for the women with follow-up and therefore our rate of 18% could be overestimated if only the highest-risk women presented, or could be underestimated if the highest-risk women did not present for their follow-up visit. The high rate of African-American women receiving care at one urban institution may make these results less generalizable; however, it is also important to focus on this specific group of women known to be at the highest risk for long-term cardiovascular outcomes.7 Lastly, we used the need for antihypertensive agents in someone previously not on them as a definition for persistent hypertension. There were seven women who were normotensive on their antihypertensive agents at the 6-week visit. It is plausible that some of these women were kept on their medication without a trial off of medication and may have, in fact, been normotensive. This would have inappropriately classified them with persistent hypertension and biased our results. The postpartum period is a unique opportunity for healthcare providers to educate women about their lifetime cardiovascular risk after preeclampsia and possibly alter modifiable risk factors. It is important to continue to identify women at highest risk for poor follow-up and persistent hypertensive disease. Future research should be focused on strategies to improve postpartum follow-up, especially among the women identified in our study to be at high risk of not attending their visit and at high risk of persistent hypertension.
Author Manuscript
Acknowledgments This study was funded in part by a career development award in Women's Reproductive Health Research: K12HD001265-14.
References
Author Manuscript
1. American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy: report from the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013; 122:1122–1131. [PubMed: 24150027] 2. Andersgaard AB, Acharya G, Mathiesen EB, Johnson SH, Straume B, Oian P. Recurrence and longterm maternal health risks of hypertensive disorders of pregnancy: a population-based study. Am J Obstet Gynecol. 2012; 206(143):e1–e8. 3. Wilson BJ, Watson MS, Prescott GJ, Sunderland S, Campbell DM, Hannaford P, Smith WC. Hypertensive disease of pregnancy and risk of hypertension and stroke in later life: results from cohort study. BMJ. 2003; 326:845. [PubMed: 12702615] 4. Bellamy L, Cases JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. 2007; 335:974. [PubMed: 17975258] 5. McDonald SD, Malinowski A, Zhou Q, Yusuf S, Devereaux PJ. Cardiovascular sequelae of preeclampsia/eclampsia: a systematic review and meta-analyses. Am Heart J. 2008; 156:918–930. [PubMed: 19061708]
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Table 1
Demographic information for the entire cohort*
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Characteristic
Cohort (n=193)
Age (years)a
25.0 (21.2–30.4)
BMI (kg/m2)
