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Peripartum and Postpartum Management of Women with Hypertensive Disorders of Pregnancy

Key Questions Aug 12, 2021
Peripartum and Postpartum Management of Women with Hypertensive Disorders of Pregnancy

Background

The Patient-Centered Outcomes Research Institute (PCORI) is partnering with the Agency for Healthcare Research and Quality (AHRQ) to develop a systematic evidence review on the peripartum and postpartum management of women with hypertensive disorders of pregnancy (HDP). PCORI and AHRQ are collaborating with the American College of Obstetricians and Gynecologists (ACOG) which plans to develop evidence-based clinical guidance informed by the review.

HDP encompass preeclampsia/eclampsia/HELLP syndrome (Hemolysis, elevated liver enzymes, low platelet count), gestational hypertension, chronic hypertension and preeclampsia superimposed on chronic hypertension.(1) A woman can be diagnosed with one of these disorders during pregnancy or the symptoms can emerge de novo in the postpartum period.

The number and rate of women experiencing HDP in the United States has risen substantially over the last two decades and this group of conditions now affects up to 10% of all U.S. pregnancies.(2) Women who experience HDP are at greater risk of morbidity and mortality in the short- and long-term and this association is more pronounced among women of color.(3) For example, pregnancies affected by preeclampsia/eclampsia are associated with a 13-fold increased incidence of myocardial infarction, 14.5-fold of stroke and 6.4-fold of overall death compared to pregnancies without these conditions and these risks remain elevated and significant up to and greater than 3 years postpartum.(4) Women with HDP not only have significantly increased risk of pregnancy-related complications but they are also at increased risk of future cardiovascular disease such as chronic hypertension, heart failure, stroke, atrial arrhythmias, coronary heart disease and mortality.(5) 

Over the past 20 years, pregnancy-related deaths have increased in the U.S. (increasing from 7.2 deaths per 100,000 live births in 1987 to 17.3 in 2017)(6) and over half of the pregnancy-related deaths in the U.S. occur in the postpartum period.(7) Currently, maternal mortality rates are higher in the U.S. than in any other industrialized country.(8) The CDC reports that about 7% of the pregnancy-related deaths between 2014 and 2017 were attributable to HDP. In addition, HDP may also contribute to other pregnancy-related deaths, particularly those caused by cerebrovascular accidents and other cardiovascular conditions which account for about one-quarter of pregnancy-related deaths.(9) Cardiovascular disease is now the foremost cause of death among pregnant and postpartum women in the U.S.(10)

Although some guidelines highlight the number of women with HDP and the negative consequences of the disorder, there are few, if any, guidelines focused on the management of women with HDP in the peripartum and postpartum periods. Existing guidelines primarily examine management of HDP in the antenatal period and provide limited information about management in the peripartum and postpartum periods.(11-13)

Related existing systematic reviews have limitations as well. Although postpartum treatment of women with HDP was last covered by a systematic review in 2017 and, prior to that, by a 2013 Cochrane review, many questions remain.(14, 15) Monitoring/telemonitoring of postpartum hypertension may be on the cusp of wider use and an up-to-date systematic review in the area could be beneficial to the field. Although there is consensus around the benefits of magnesium sulfate for the prevention and treatment of eclampsia, questions remain about its optimal regimen (16, 17) and a 2020 systematic review focused only on a narrow aspect of the field.(18) Given the increase in the number of U.S. women with HDP, the significant health consequences and the lack of evidence synthesis in this area, ACOG is interested in a systematic review of the peripartum and postpartum management of women with HDP. 

Draft Key Questions

  1. What are the effectiveness and harms of monitoring/telemonitoring interventions for the management of postpartum women who experienced hypertensive disorders of pregnancy? Do the effectiveness and harms vary by disease severity?
  2. What are the effectiveness, comparative effectiveness and harms of medical management of postpartum women with hypertensive disorders of pregnancy?
  3. What is the optimal treatment regimen of magnesium sulfate for peripartum and postpartum women with preeclampsia with severe features? Are there harms associated with the use of any particular anti-hypertensive medications and the administration of magnesium sulfate?

For all key questions, how do the findings vary by race and/or ethnicity?

Table 1: PICOTS for Postpartum and Peripartum Management of Women with HDP

Inclusion Criteria Exclusion Criteria
Population:

KQ1. Postpartum women with HDP arising in pregnancy or de novo in the postnatal period or at high risk for HDP
KQ2. Postpartum women with HDP arising in pregnancy or de novo in the postnatal period
KQ3. Peripartum women with pre-eclampsia with severe features

 

KQ1&2/KQ3: Women outside of the postpartum period; women >1 yr postpartum
KQ3: Pregnant or postpartum women outside of the peripartum period

Intervention:

KQ1. Postpartum blood pressure monitoring interventions including telemonitoring, home blood pressure monitoring, self- or text-based monitoring, etc.
KQ2. Medical management of postpartum hypertension including antihypertensive medications, loop diuretics, parenteral steroids, uterine curettage and low-dose aspirin.
KQ3. Peripartum administration of magnesium sulfate

 

KQ1. Blood pressure monitored in traditional clinic visits
KQ2. Non-medical interventions including meditation, traditional medicine, etc.

Comparator

KQ1&2: Standard of care; different type of care or intervention; no intervention
KQ3: Other dosing strategy with magnesium sulfate

 

No comparator

Outcomes

KQ1. Maternal health outcomes: Ascertainment of blood pressure; blood pressure control; initiation or increase in antihypertensive medications
Maternal experience: Patient knowledge; maternal satisfaction
Resource utilization: Hospital readmission; emergency room visits
Harms: Adverse events or other harms, including generation or exacerbation of health inequities
KQ2. Maternal health outcomes: Blood pressure control; length of postnatal hospital stay; postpartum maternal mortality; postpartum maternal morbidity; breastfeeding outcomes
Infant-related outcomes: Safety of medication for breastfeeding infant
Maternal experience: Maternal satisfaction
Resource utilization: Postpartum hospital readmission; emergency room visits
Harms: Neuromuscular blockade, severe hypotension and/or other harms due to use of calcium channel blockers among women treated with magnesium sulfate; adverse events
KQ3. Seizures; flushing; time to ambulation and lactation; duration of magnesium sulfate administration; maternal satisfaction; toxicity; other adverse events or harms; maternal death

 
Timing

KQ1&2: Day of birth up to 1 year postpartum
KQ3: Peripartum period

 
Setting

KQ1&2. Setting not limited
KQ3. Hospital setting only

 
Study Design

Clinical trials; crossover designs

 

Case-control, cohort, linkage studies; Cross-sectional studies; focus groups, qualitative studies, feasibility studies or descriptive studies that characterize the intervention or the population (this is an issue for the clinics)

 

Draft Analytic Framework

This figure depicts the Analytic Framework for Key Questions 1 to 3 within the context of the eligibility criteria described below. In general, the figure illustrates the potential effects and harms of monitoring, medical management (including pharmacologic and curettage) and administration of magnesium sulfate in women in the peripartum or postpartum period with hypertensive disorders of pregnancy (HDP). The figure shows the comparison of monitoring (key question 1) and medical management (key question 2) and administration of magnesium sulfate (key question 3) in women in the peripartum or postpartum period with HDP to standard of care, different types of care or intervention or no intervention. Interventions may result in a range of health outcomes including intermediate outcomes of blood pressure ascertainment and control, time to ambulation, ER visit or hospital readmission, patient knowledge, seizures, maternal satisfaction, maternal morbidity and maternal mortality. All interventions may have harms, which include underuse of care and missed rise in blood pressure (key question 1), severe hypotension and neuromuscular blockade (key question 2) and toxicity and flushing (key question 3).

 

Definition of Acronyms

Acronyms Definition

ACOG

American College of Obstetricians and Gynecologists

HDP

Hypertensive Disorders of Pregnancy

HELLP

Hemolysis, elevated liver enzymes, low platelet count

PCORI

Patient-Centered Outcomes Research Institute

 

References

  1. August P, Sibai B. Hypertensive disorders in pregnancy: Approach to differential diagnosis. In: Barss VA, editor. UpToDate. Waltham, MA (Accessed on March 26, 2021): UpToDate.
  2. Centers for Disease Control and Prevention. Data on selected pregnancy complications in the United States 2019 [updated February 28, 2019;March 26, 2021].
  3. Petersen EE, Davis NL, Goodman D, Cox S, Syverson C, Seed K, et al. Racial/Ethnic Disparities in Pregnancy-Related Deaths - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2019;68(35):762-5. doi: 10.15585/mmwr.mm6835a3. PMID: 31487273.
  4. Lin YS, Tang CH, Yang CY, Wu LS, Hung ST, Hwa HL, et al. Effect of pre-eclampsia-eclampsia on major cardiovascular events among peripartum women in Taiwan. Am J Cardiol. 2011;107(2):325-30. doi: 10.1016/j.amjcard.2010.08.073. PMID: 21211611.
  5. Coutinho T, Lamai O, Nerenberg K. Hypertensive Disorders of Pregnancy and Cardiovascular Diseases: Current Knowledge and Future Directions. Curr Treat Options Cardiovasc Med. 2018;20(7):56. doi: 10.1007/s11936-018-0653-8. PMID: 29923067.
  6. Melchiorre K, Sharma R, Thilaganathan B. Cardiovascular implications in preeclampsia: an overview. Circulation. 2014;130(8):703-14. doi: 10.1161/CIRCULATIONAHA.113.003664. PMID: 25135127.
  7. Davis NL, Smoots AN, Goodman DA. Pregnancy-Related Deaths: Data from 14 U.S. Maternal Mortality Review Committees, 2008-2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2019.
  8. Grodzinsky A, Florio K, Spertus JA, Daming T, Schmidt L, Lee J, et al. Maternal Mortality in the United States and the HOPE Registry. Curr Treat Options Cardiovasc Med. 2019;21(9):42. doi: 10.1007/s11936-019-0745-0. PMID: 31342274.
  9. Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System [updated November 25, 2020; March 26, 2021].
  10. American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Washington, D.C.: 2013.
  11. National Institute for Clinical Excellence (NICE). Hypertension in pregnancy: diagnosis and management (NICE Guideline 133). 2019.
  12. Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, et al. Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice. Hypertension. 2018;72(1):24-43. doi: 10.1161/HYPERTENSIONAHA.117.10803. PMID: 29899139.
  13. ACOG Committee Opinion No. 767 Summary: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol. 2019;133(2):409-12. doi: 10.1097/AOG.0000000000003082. PMID: 30681541.
  14. Cairns AE, Pealing L, Duffy JMN, Roberts N, Tucker KL, Leeson P, et al. Postpartum management of hypertensive disorders of pregnancy: a systematic review. BMJ Open. 2017;7(11):e018696. doi: 10.1136/bmjopen-2017-018696. PMID: 29187414.
  15. Magee L, von Dadelszen P. Prevention and treatment of postpartum hypertension. Cochrane Database Syst Rev. 2013(4):CD004351. doi: 10.1002/14651858.CD004351.pub3. PMID: 23633317.
  16. Duley L, Matar HE, Almerie MQ, Hall DR. Alternative magnesium sulphate regimens for women with pre-eclampsia and eclampsia. Cochrane Database Syst Rev. 2010(8):CD007388. doi: 10.1002/14651858.CD007388.pub2. PMID: 20687086.
  17. Norwitz ER. Preeclampsia: Management and Prognosis. In: Barrs VA, editor. UpToDate. Waltham, MA (Accessed on March 29, 2021): UpToDate; 2021.
  18. Yifu P, Lei Y, Yujin G, Xingwang Z, Shaoming L. Shortened postpartum magnesium sulfate treatment vs traditional 24h for severe preeclampsia: a systematic review and meta-analysis of randomized trials. Hypertens Pregnancy. 2020;39(2):186-95. doi: 10.1080/10641955.2020.1753067. PMID: 32338165.

Project Timeline

Peripartum and Postpartum Management of Women with Hypertensive Disorders of Pregnancy

Aug 12, 2021
Topic Initiated
Aug 12, 2021
Key Questions
Page last reviewed September 2021
Page originally created February 2021

Internet Citation: Key Questions: Peripartum and Postpartum Management of Women with Hypertensive Disorders of Pregnancy. Content last reviewed September 2021. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/products/hypertensive-disorders-pregnancy/draft-comments

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