Reducing Long-Term CV Risks after Preeclampsia through Online Intervention and Communication

An online intervention program for women who recently had preeclampsia has produced insight into how to reduce their future risks of cardiovascular disease.

A Brigham and Women’s Hospital team co-led by clinician-researcher Ellen W. Seely, MD, and epidemiologist Janet Rich-Edwards, ScD, MPH, set out to determine which tools and information would be most useful for new mothers.

“Often there’s an assumption that the woman is not ready to hear about the cardiovascular risks associated with preeclampsia or that someone else has told her. But we found that these women are ready and they do want to hear — and this is the window in which the information can have impact,” said Seely, director of Clinical Research for the Brigham’s Endocrinology, Diabetes and Hypertension Division. Rich-Edwards has studied preeclampsia in large populations and directs developmental epidemiology at the Mary Horrigan Connors Center for Women’s Health and Gender Biology.

Working with the Preeclampsia Foundation, which provided patient input, the Brigham research team created Heart Health for Moms (HH4M), an internet-based lifestyle intervention program that includes online educational modules, a community forum and communication with a lifestyle coach. In a randomized controlled trial, 151 women who had preeclampsia within the prior five years were assigned to either the active intervention or a control intervention that offered static educational resources about CV risks associated with preeclampsia and related lifestyle recommendations.

After nine months, participants in the intervention group reported significantly greater knowledge of cardiovascular disease risk factors, increased self-confidence in their ability to stick to a healthy diet and less physical inactivity than women in the control group. Results were published in the Journal for Women’s Health in June. The research team included Louise E. Wilkins-Haug, MD, PhD, director of the Division of Maternal-Fetal Medicine in the Brigham’s Department of Obstetrics and Gynecology.

Patients – and Some Physicians – May Be Unaware of Risks

Retention and participation rates for both arms of the study were high (> than 90 percent), especially compared to more traditional face-to-face interventions. In the active intervention arm, 84 percent of participants accessed at least one online educational module and 89 percent completed at least three scheduled calls with the coach.

Among women who received the active intervention, the researchers found significant improvement in cardiovascular disease risk knowledge, self-efficacy to achieve a healthy diet and reduction in physical inactivity. The groups did not differ in the sense of personal control of cardiovascular disease risk factors, adherence to the DASH diet, self-efficacy for physical activity or reported physical activity. Funding for this project was provided by the Patient Centered Outcomes Research Institute (PCORI).

“Many women — and even physicians — don’t realize that preeclampsia is associated with cardiovascular disease after pregnancy,” said Seely, whose research has focused on gestational diabetes and preeclampsia and their relationship to future health. “Education is a big component of our intervention; you can’t prevent something if you don’t know you’re at risk for it.”

Desire to Know Impact of Preeclampsia for Health and Family

Other insights came from working with patients to create the intervention, as well as from the study results:

  • Importance of incorporating patient viewpoints and lifestyle needs: Listening to patient input about the time demands on a new mother led to development of online education and other resources that were mobile-enabled and available 24-7, without travel to a medical office or a community location.
  • Emotional and mental health impact of preeclampsia: “We hadn’t been thinking about Post Traumatic Stress Disorder (PTSD) as a possible outcome of preeclampsia until we started listening to the women themselves,” said Rich-Edwards. When women shared their birth stories in a community forum, it was evident that many experienced PTSD symptoms. “Acknowledging the emotional difficulty of preeclampsia was necessary before some women were able to engage with lifestyle improvements. This has made us think differently about how you reach women after a traumatic pregnancy.”
  • Defining and communicating about active lifestyle: The researchers found that clarifying the meaning of “activity,” “inactivity” and formal exercise taught women that pushing a baby stroller and active household chores all accrued to good health.
  • The responsibility of all providers to educate patients about CV risks after preeclampsia: Lack of women’s awareness of CV risks after preeclampsia suggested the need for a detailed hand-off between maternal-fetal specialists and community obstetricians to whom patients return – and for both groups (as well as internists, family practitioners and other providers) to educate patients about risks and heart-healthy strategies. “Pregnancy is not just an isolated nine months in women’s lives, either physiologically or psychologically,” Seely said. “We need to think more about the continuity of care and enhance programs for these women.”
  • Preeclampsia as an opportunity for health education: Because many women experience preeclampsia as their first major health event, it is an opportunity for education about healthy habits for their entire household. “Patients said that they were motivated to improve their diet during pregnancy and wanted to continue a healthy lifestyle after pregnancy,” said Rich-Edwards. “The study overall revealed a real desire for women to have a way to process what this condition means for them, their health and the health of their family. The strength of that desire surprised me.”