Strong evidence that now connects preeclampsia with long-term maternal cardiovascular risks raises new questions for obstetricians (OBs): What is the best way to care for women after preeclampsia? And, what postpartum care and support might help women minimize immediate and long-term risks?
The Cardiometabolic Clinic, a postpartum transition clinic at Brigham and Women’s Hospital, is providing some answers. The innovative program, believed to be the first of its kind in the United States, focuses on women’s immediate complex care needs after hospital discharge, provides education about cardiovascular risk and assists transition to a primary care provider (PCP) to continue care.
The clinic is led by Ann C. Celi, MD, MPH, from the Division of General Internal Medicine and Primary Care, in conjunction with Louise Wilkins-Haug, MD, PhD, director of the Division of Maternal-Fetal Medicine and Reproductive Genetics and Ellen Seely, MD, director of clinical research in the Division of Endocrinology, Diabetes and Hypertension.
Since the clinic began in 2011, its leaders have found that postpartum women gladly accept and use home blood pressure monitors; adhere to medication regimens; and are sufficiently engaged to attend scheduled visits at the postpartum clinic, nutrition consultations and primary care follow-up.
These results run contrary to prior thinking that new mothers are too preoccupied to prioritize their own care.
“We now know that if you empower women with information, they will show up, they will take their medications and they will monitor their blood pressure at home,” said Dr. Wilkins-Haug.
The Surprising Power of Providing Home Blood Pressure Monitors after Preeclampsia
Dr. Celi sees patients during a weekly half-day clinic that is located within the Maternal-Fetal Medicine practice. Most of the women gave birth at Brigham and Women’s Hospital and have antepartum hypertension, postpartum hypertension or other hypertensive conditions.
Visits focus on hypertension management and medication titrations, identifying other medical and postpartum concerns and creating a bridge to primary care. Patient education includes nutrition, lactation support and self-care.
The clinic builds upon the research led by Brigham epidemiologist Janet Rich-Edwards, SCD, MPH that has helped to establish the relationship between pregnancy-related conditions (particularly gestational diabetes and preeclampsia) and health problems later in life. As Celi, Wilkins-Haug and Seely expanded their focus to include how best to address these ongoing risks, they conducted a survey of internal medicine and obstetric faculty. The results revealed knowledge gaps regarding long-term cardiovascular disease risks, which helped to define the work of the transition clinic.
Once the clinic was underway, one surprise was the success and significance of providing a way for women to take their own blood pressure at home.
“Providing home blood pressure monitors to patients at the time of discharge has been the most important element of the program,” said Dr. Celi. “It puts care in the women’s own hands. That can be empowering.”
Findings from the First Five Years of a Postpartum Transition Clinic
Leaders of the Cardiometabolic Clinic recently reported results in Maternal and Child Health Journal on 412 patients from the clinic’s first five years, 2011 – 2016. Highlights include:
- Median time to first visit was 16 days after delivery, and most women had a total of 2 to 3 visits. This is consistent with the 2018 revision of American College of Obstetrician and Gynecologists guidelines that now recommend that all women have contact with an obstetric care provider within 3 weeks of giving birth and that care should be ongoing.
- Nearly half of women had adjustments to antihypertensive medications while patients at the clinic. “Often women will leave the hospital on several medications and we need to try to hone those down if we’re going to get compliance,” Dr. Wilkins-Haug said.
- Of patients scheduled for a nutrition consultation, 79 of 91 (86.8%) attended the appointment. For patients with primary care providers within the Brigham’s network, 105 of 132 (79.5%) kept their scheduled follow-up appointment.
- Acquisition of home blood pressure monitors increased from approximately 57% to 94% of women over the five years as funding was secured.
Women’s eagerness to be involved in their care echoed other recent findings by Brigham researchers regarding an online intervention program aimed at improving long-term heart health after preeclampsia.
OBs can Choose “A La Carte” What Might Work in their Own Practices
One goal of publishing the new report about the Cardiometabolic Clinic was to provide a platform for broader use by OBs and PCPs, said Dr. Celi. One appendix describes specific actions taken in the transition clinic, including a transition plan and education materials used. From this, physicians “can choose a la carte which to provide in their own practice,” Dr. Celi said.
The second appendix contains a sample letter that specialists can send to primary providers so care plans continue without interruption. The letter provides an example summary of a patient’s postpartum care to date and suggests timing for subsequent steps and primary cardiovascular prevention strategies.
“I expect that obstetricians will get creative about how they implement some of these issues,” said Dr. Wilkins-Haug. “It’s a challenge to busy OBs to bring this increased work into their practice – but I think we’ll see more telemedicine, more online communication between the patient and the doctor’s office, and maybe even partnering with pediatric offices for women to provide a little more education and check blood pressure.”
“The idea is not that we want to replicate these clinics everywhere, but really have the OB/GYN try to reframe how they approach hypertension immediately postpartum, sort out what they can do in their own office and identify that rare individual who may need an internist involved,” she added. “A lot of women do not have access to high-risk care programs. But obstetricians can take pieces of what we’ve done here and craft that into what’s going to work best for their patients.”