Interpregnancy Care After Preeclampsia: A Call to Action for Primary Care and Maternal Subspecialty Clinicians

In this issue, Ragnarsdottir et al. assessed the impact of interpregnancy development of chronic hypertension after preeclampsia on subsequent pregnancy outcomes. Compared with the normalization of postpartum blood pressures (BPs), the development of chronic hypertension was associated with an increased risk of preterm preeclampsia.1 This is consistent with prior work establishing that both preexisting and interpregnancy chronic hypertension are associated with recurrent preeclampsia.2 This study is significant given its large sample size afforded by the National Swedish Medical Registry. They also performed a unique analysis to assess the interaction between preeclampsia and interpregnancy chronic hypertension. They found a synergistic interaction resulting in an increased risk for preterm preeclampsia that was greater than the sum of each individual risk factor. Study limitations include the lack of clear diagnostic criteria for superimposed preeclampsia, which remains a challenging diagnosis. Additionally, the authors acknowledge that the management of chronic hypertension in pregnancy has changed since the study period. For example, aspirin use, formally recommended by the USPSTF in 2018 for preeclampsia prevention, is likely more frequently prescribed now than prior.3 In the study population, medication therapy for chronic hypertension was initiated with a goal BP of less than 150 mm Hg systolic and 100 mm Hg diastolic. Recent findings from the Chronic Hypertension and Pregnancy (CHAP) study have shifted the recommendations for treatment goals to less than 140 mm Hg systolic and 90 mm Hg diastolic during pregnancy, shown to reduce the risk of developing superimposed preeclampsia.4 Nevertheless, this study adds to our understanding of the longitudinal effects of preeclampsia and has broad implications for interpregnancy care. When considering the study implications for the United States, there are population-level differences to consider. While the incidence of preeclampsia in this Swedish study population was approximately 4%, it is closer to 9% in the United States, and as high as 11% among pregnancies in Black individuals.5 Additionally, rates of interpregnancy chronic hypertension are significantly higher in the United States. In the Heart Health Study, the incidence of chronic hypertension within 2–7 years of an initial pregnancy was 20% and the rate was even higher among those with prior preeclampsia at approximately 37%.6 In addition to the development of chronic hypertension, there is growing recognition of the long-term maternal cardiovascular health implications after preeclampsia. Multiple prior studies have shown that preeclampsia is associated with accelerated atherosclerotic disease in the carotid and coronary arteries.7,8 Individuals with a hypertensive disorder of pregnancy who developed chronic hypertension have the highest proportion of left ventricular remodeling 8–10 years after delivery.9 Furthermore, individuals with recurrent preeclampsia have a 3-fold increased risk of heart failure and almost a 2-fold risk of overall cardiovascular disease when compared with those with a single event and subsequent uncomplicated pregnancies.10 Given the findings of the current study and the increased risk of preterm preeclampsia with interval hypertension development, there should be a strong push for primary prevention following preeclampsia to reduce the incidence of postpartum chronic hypertension. Given our growing understanding of the long-term impact of preeclampsia, there has been a renewed focus on postpartum interventions to promote sustainable health improvement. In the Long-Term Blood Pressure Control After Hypertensive Pregnancy Following Physician-Optimized Self-Management (POP-HT) trial, individuals with preeclampsia were randomized to standard of care or BP self-monitoring combined with physician-guided medication adjustment during the first 6 weeks postpartum. The intervention arm had a 6.5-mm Hg improvement in systolic BP,11 reduced left atrial and ventricular mass, and improved systolic and diastolic function, up to 9 months postpartum.12 The benefits of remote BP monitoring were also demonstrated in a systematic review by Steele et al.13 Home monitoring programs increase ascertainment of postpartum BPs, reduce racial disparities, and probably decrease hypertension-related postpartum hospital readmission. Aggressive, structured BP management in the immediate postpartum period is an important cornerstone of care to provide long-lasting cardiovascular health improvements. The implementation of longitudinal healthcare interventions following pregnancy in the United States carries challenges that are not faced in other developed countries due to the lack of universal healthcare coverage after pregnancy. During pregnancy, individuals can be connected to the healthcare system through Medicaid, which covers about 40% of births annually and is guaranteed for all pregnant persons.14 Just in the past 2 years, 47 states have expanded postpartum Medicaid, with Arkansas, Iowa, and Wisconsin still yet to do so. In a comparison of states with and without a Medicaid expansion policy since the passage of the Affordable Care Act, expansion was associated with a 17% lower rate of postpartum hospitalization at 60 days and a slightly lower rate at 6 months.15 To ensure the success of long-term postpartum interventions, we must continue to work toward national Medicaid expansion and postpartum insurance coverage to allow access to necessary preventive healthcare services. Continued work in the expansion of healthcare access must incorporate efforts aimed at improving outcomes in minority populations. Within the United States, the maternal mortality rate is highest for non-Hispanic Black birthing people, who have a rate that is 2–3 times the rate for White individuals.16 Doula care during pregnancy is associated with a lower incidence of preterm birth, low birth weight, and C-sections and recent evidence has shown doula care can reduce pregnancy-related disparities.17 Incorporation of Doula services may also aid in reducing racial disparities in postpartum cardiovascular outcomes. There are currently at least 2 active clinical trials, including one at our institution, underway to assess if the incorporation of Black community doulas can improve postpartum BP and cardiometabolic health (STUDY22060056; STUDY27919). Lastly, effective postpartum management after preeclampsia involves structured transitions of care. Recent studies have suggested that as few as 60% of individuals attend a postpartum appointment.18 Historically, the postpartum visit has been a nominal, one-size-fits-all 6-week postdelivery appointment but in 2018, ACOG endorsed an updated Committee Opinion to provide further guidance for a more dynamic postpartum care.18 Similarly, The American Heart Association endorsed a scientific statement aimed at providing a framework for postpartum care to reduce the risk of cardiovascular disease.19 Postpartum care after preeclampsia should be individualized for cardiovascular prevention and involve supporting specialties and ancillary services. This includes close interval postpartum visits with telehealth BP monitoring, referral to a pregnancy heart team, and transitioning care to a longitudinal clinician. All practitioners who provide routine postpartum care have a key role in facilitating warm handoffs to the providers who will continue to care for their patients. Multidisciplinary postpartum clinics can offer a unique space to address postpartum hypertension, particularly when run jointly with obstetricians and maternal subspecialists (primary care, cardiology, or nephrology). A key piece of postpartum care in these clinics involves offering virtual visits, which have been shown to be feasible and effective for a racially and socioeconomically diverse cohort.20 Novel and flexible clinical approaches to postpartum care may help increase compliance and follow-up for our most complex and vulnerable patients. The work by Ragnarsdottir et al. reinforces the impact of preeclampsia and interval development of chronic hypertension on future pregnancy outcomes and highlights the need for more optimal care during the “fourth trimester” to prevent long-term cardiovascular complications for our patients. We offer a model of care in Figure 1 showing multidisciplinary opportunities for intervention in the interpregnancy period to improve pregnancy and cardiovascular outcomes. As pregnancy is often seen as a litmus test of future health, collaboration between obstetricians, primary care teams, and cardiologists is important to bridge care during the reproductive years. Opportunities for intervention in the postpartum period following a pregnancy complicated by preeclampsia and after recurrence. This work was supported by NIH/NHLBI K23HL168356 to A.H. The authors declared no conflict of interest.