Heart failure with preserved ejection fraction: A growing global epidemic
CDC Change Package Offers Menu Of Strategies To Prevent, Manage Hypertension In Pregnancy
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Key takeaways:SAN FRANCISCO — Effective strategies to prevent and manage hypertensive disorders of pregnancy are often underutilized, but a new CDC initiative aims to harness solutions that work and package them in one place for busy clinicians.
The CDC's National Center for Chronic Disease Prevention and Health Promotion released a Hypertension in Pregnancy Change Package, developed in partnership with ACOG and other leading authorities in maternal health, which serves as an evidence-informed listing of process improvements with accompanying tools and resources for clinicians caring for pregnant and postpartum women.
A CDC Million Hearts change package includes evidence- or practice-based tools for preventing and managing gestational hypertension. Image: Adobe Stock.
The focus of the change package is early identification, optimal management and prevention of complications of hypertension in pregnancy.
"Hypertension of any type during pregnancy marks a women for having elevated risk for heart disease and stroke," Janet S. Wright, MD, MACC, FPCNA, director of the division for heart disease and stroke prevention and the National Center for Chronic Disease Prevention and Health Promotion at the CDC, said during a press conference at the ACOG Annual Clinical & Scientific Meeting. "Forty percent to 50% of women with hypertension during pregnancy are hypertensive at 6 weeks [after delivery]; about 40% with severe preeclampsia are hypertensive at 1 year. You get stuck with this tattoo."
Janet S. Wright
As Healio previously reported, hypertensive disorders of pregnancy are the second leading cause of maternal death behind maternal hemorrhage and are a significant cause of short- and long-term maternal and offspring morbidity worldwide. Prior research indicates hypertension develops faster among women who experienced hypertensive disorders of pregnancy, up to 10 years earlier, compared with women with normotensive pregnancies.
For pregnant and postpartum women, poorly controlled hypertension can have serious implications, including markedly increased risk for stroke, Wright said. Despite the risks, hypertension prevalence is likely underestimated; measurements are often done incorrectly and clinical inertia contributes to poor BP control.
"Overall, we know that because of this epidemic of hypertension, more women are going into pregnancy with hypertension, often undetected," Wright said. "If detected, it is often uncontrolled. It is a systems issue and it needs a systems solution."
Strategies to support healthy pregnanciesTo assist health care professionals, CDC's Million Hearts initiative, in collaboration with experts in women's, maternal, and fetal health and hypertension, developed the Hypertension in Pregnancy Change Package. The guide, which Wright described as a "menu" of more than 350 proven strategies from collaborators all over the United States, contains tools to help busy outpatient clinical teams effectively detect and manage hypertension both during and after pregnancy.
The guide includes strategies to support home-monitored or out-of-office BP; aspirin use to prevent preeclampsia; recommendations for a healthy lifestyle; and the use of anti-hypertensive medications that are safe and effective during pregnancy and lactation. The change package also includes information on how to help patients access antihypertensive medications specifically recommended for pregnant women, which may not always be the lowest priced options or the options covered by health plans, Wright said.
"Knowing is not doing," Wright said. "This package was envisioned as a tool to help busy outpatient clinical teams turn 'what works' into 'what happens' in their practice. This is for people across the spectrum — primary care, OB/GYN, cardiology. Getting focused on the latest evidence and what the strategies are will have the greatest return."
Use tailored interventionsWright cautioned that hypertensive disorders of pregnancy do not affect all women equally. Black and Indigenous women have higher rates of elevated BP and lower rates of hypertension control, as do women living in the South, Midwest or in more rural parts of the U.S. These populations require tailored interventions, which are also addressed in the package.
The change package is broken down into four focus areas:
"What makes me optimistic about this is never have we lived in a time where the evidence is more solid about what to do," Wright said. "There is also a lot of attention on women's health, maternal health and making the connection to hypertension.
"What I hope is that people get a sense of, 'this is doable,'" Wright said. "[The package has] bite size pieces and bigger pieces. We do not presume to know the best fit for a practice. There are resources from places that have used these tools."
Wright stressed that any strategies outlined in the package should first be tested on a small scale — conducting "small tests of change" — to assess feasibility and allow the team to evaluate and adjust before instituting the change on a broader, more permanent scale. The CDC does not recommend that any practice attempt to implement all of the interventions at once, nor is it likely that all interventions will be applicable to all clinical settings.
Wright said ongoing issues continue to need attention, including more resources to address gaps in care for women with hypertension during the first year after delivery.
"The ability to conduct timely detection and management of hypertension in pregnancy means we are investing in generational health," Wright said. "It is not about managing that woman during pregnancy. It is about managing that woman for the rest of her life."
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Mayo Research Shows High Blood Pressure In Pregnancy Can Have Lasting Effects. Here's What You Should Know
ROCHESTER — High blood pressure impacts roughly 1 out of every 13 pregnancies, making conditions such as chronic hypertension and pre-eclampsia relatively common complications.
While these conditions have short-term impacts on a pregnant person's body, a recent Mayo Clinic study used locally sourced data to show how high blood pressure in pregnancy can contribute to health issues years later for mothers and their biological children.
"Our question for offspring was: Is this really a family history of hypertension — that mother developed later in life — that is putting them at risk for hypertension?" said Dr. Vesna Garovic, chair of Mayo Clinic's Division of Nephrology & Hypertension and the senior author of the study. "Or is it the fact that they were actually products of pregnancies that were complicated by hypertension?"
Garovic and her co-authors used data from the Rochester Epidemiology Project to review the health records of nearly 9,000 people born to about 7,500 area women from 1976 and 1982. Now that the babies born in this cohort are in their 40s, the researchers could see if people born from hypertensive pregnancies had a greater chance of developing hypertension in adulthood.
Here are the main takeaways from this new research, which was published on July 25 in the journal Hypertension.
1. Several types of high blood pressure were included in the study.
Previous studies, Garovic said, have looked at the impacts of pregnancy-related blood pressure conditions, also known as hypertensive disorders of pregnancy. These conditions, which include gestational hypertension and pre-eclampsia, cause high blood pressure during pregnancy. Past research has looked at this link between pregnancy-related hypertension and the risk of developing chronic high blood pressure later in life for mother and child, Garovic said.
"A woman who has hypertension in pregnancy, including pre-eclampsia, is at risk for hypertension later in life," Garovic said.
In this study, the researchers included hypertensive disorders of pregnancy as well as maternal chronic hypertension, defined as "a diagnosis of chronic hypertension in the offspring's mother before, during or after pregnancy." Put simply, this refers to high blood pressure in the mother that is unrelated to a previous or future pregnancy.
The data, Garovic said, point to children having an increased risk of high blood pressure even if their mothers developed high blood pressure after that pregnancy.
"We actually found out that it is both hypertension in pregnancy and maternal hypertension later in life, that they're putting offspring at risk of hypertension," Garovic said.
2. Family history and preventive care are important.
Having high blood pressure while pregnant increases one's future risk of hypertension, and being exposed to high blood pressure while in utero can increase one's future risk of hypertension, type 2 diabetes, childhood asthma and altered cardiac structure.
It is important for patients and their health care providers to know this information, Garovic said, and to pay attention to lifestyle factors for managing their blood pressure, such as diet and exercise.
"Pediatricians should elicit this important history from the mothers of the patients," Garovic said. "People born from hypertensive pregnancies should bring that to their physician and may need more health monitoring and screening and should be provided timely medical advice about diet, exercise and other lifestyle measures to reduce the risks."
3. High blood pressure in pregnancy is becoming more common.
Garovic said pre-existing high blood pressure before pregnancy is relatively rare because people who are in their 20s and 30s are less likely to have that condition. But because more women are waiting longer to have children, more patients are entering pregnancy with hypertension.
"Women in their 30s, even 40s, when they get pregnant, they maybe are more chronically hypertensive," Garovic said. "There are also these sophisticated measures for treatment of infertility that, on their own, can be associated with greater risk of hypertension in pregnancy, such as in vitro fertilization."
4. There's still more to learn.
Garovic and her co-authors' study builds into a growing field of research on how exposures to different conditions in the womb have long-term effects on the children born from those pregnancies.
"There is a huge interest in what we call fetal origins of adult disease," Garovic said. "This study is aligned (with) that sort of way of thinking that, indeed, in your health, an issue that you may have later in life may be defined as early as while being in utero."
Scientific knowledge of fetal origins of adult disease underlines some of the health advice given to those who are pregnant, Garovic said: avoiding alcohol, eating healthy and avoiding certain medications that are known to have negative impacts on a pregnancy.
"It means that young mothers and pregnant women should follow a healthy lifestyle, keep their weight down, eat healthy and exercise in order to improve the health of the child later in life," Garovic said.
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