Managing Hypertensive Disorders in Pregnancy with Team-Based Care

Hypertensive disorders in pregnancy are one of the leading causes of maternal and perinatal mortality worldwide and affect approximately 13-15% of all pregnancies in the United States. Hypertensive disorders of pregnancy include gestational hypertension, preeclampsia, and chronic hypertension. The incidence is rising substantially over the last few decades, and recent data reveals generational trends: pregnant individuals born between 1996 and 2004 have a near doubling of risk compared to those born in the 1950s. The most dramatic increases are among Hispanic, non-Hispanic Black, and non-Hispanic Asian or Pacific Islanders, with rate increases approaching or exceeding three times baseline risk.

Specifically, the postpartum period is a critical period for maternal morbidity and mortality; eighty percent of deaths occur within the first week post-partum. Postpartum hypertension is a continuation of a hypertensive disorder diagnosed during pregnancy or new onset hypertension. In women with antepartum preeclampsia, 50% will have persistent postpartum hypertension, and in women previously normotensive in pregnancy, approximately 8-12% develop postpartum hypertension. Risk factors include maternal age >35, Black race, obesity, C-section, and smoking history, and women most commonly present with neurologic symptoms such as headache.

Managing hypertensive disorders during and after pregnancy requires synchronized care from all members of the medical team to optimize maternal and newborn outcomes.

Antepartum, caregivers such as physicians, midwives, and nurse practitioners can manage chronic hypertension through close management of medication to keep blood pressure in an ideal range, additional antepartum testing including ultrasounds and fetal heart rate monitoring, and delivery at varying gestational ages. Gestational hypertension and pre-eclampsia also benefit additional weekly labs and twice-weekly office visits for blood pressures and antenatal testing, and delivery is recommended no later than the 37th week of pregnancy.

Hypertensive disorders in pregnancy lead to decisions for potentially preterm delivery, so consistent and correct blood pressure measurements are crucial. It is imperative that patients can take an accurate blood pressure at home, especially when patients don’t have the ability to miss work or have accessible transportation for multiple office visits. It’s recommended that patients who already have a blood pressure cuff bring their machine into the office to confirm it is functioning properly. Patients with a new diagnosis are recommended to obtain a quality blood pressure cuff for home measurement, and there are grants and programs that exist to provide free blood pressure cuffs to pregnant and postpartum patients who cannot afford to purchase their own:

• The Preeclampsia Foundation is a non-profit organization that offers resources like the Cuff Kit® which distributes kits to providers serving at-risk mothers
• The American Heart Association partners with corporations to provide kits, especially for underserved communities
• Some hospitals and health systems collaborate with insurers or non-profits to distribute free blood pressure cuffs

Pregnancy providers must be prepared to diagnose and manage hypertensive disorders with each prenatal visit and postpartum. Although risk factors exist, many cases of preeclampsia and gestational hypertension occur in healthy nulliparous patients. Preventative strategies prior to pregnancy and during pregnancy such as following a healthy diet and an active lifestyle should be encouraged, and care team members such as registered dietitians can help support patients attempting to reduce their risk.

Once hypertension has been diagnosed, non-physician team members continue to have a vital role in helping to improve patient outcomes. Having an organized and reliable protocol for patients to reach out with symptoms of hypertension or elevated blood pressures is important for optimizing patient success. The nursing line staffers, community paramedics, and community health workers they interact with during potential health crises can help provide immediate access to informed emergency care.

Blood pressure typically peaks between postpartum days 3 and 6, due to mobilization of extravascular fluid into the intravascular space and physiologic decline of vasodilatory hormones. Accurate blood pressure measurements and access to care in this timeframe is vital, and team-based care can help to alleviate the physical, logistical, and emotional challenge that postpartum hypertension care that requires leaving home soon after delivering a newborn represents. Inpatient and outpatient pharmacists can ensure patients obtain their anti-hypertensive medication in ways that are accessible to patients. The VNA has coordinated care and will see our moms at home, and our group, Bedford Commons Ob/Gyn, has come up with a protocol so that the VNA knows the blood pressure measurements or symptoms that require immediate attention and has a mechanism in place to reach an obstetric provider urgently. This ensures that follow-up is convenient for the family and reliable for the providers.

Hypertensive disorders in pregnancy can be diagnosed and managed successfully when providers have the access to accurate blood pressures and when patients have the knowledge of these conditions and access to care. Collaboration between providers and the community of health care delivery is the key to prevention and improved maternal and newborn outcomes.

Resource:

• Gestational Hypertension and Preeclampsia Practice Bulletin (ACOG)