Hypertension in Pregnancy and Postpartum: Current Standards and Opportunities to Improve Care

Abstract

Hypertension in pregnancy contributes substantially to maternal morbidity and mortality, persistent hypertension, and rehospitalization. Hypertensive disorders of pregnancy are also associated with a heightened risk of cardiovascular disease, and timely recognition and modification of associated risk factors is crucial in optimizing long-term maternal health. During pregnancy, there are expected physiologic alterations in blood pressure (BP); however, pathophysiologic alterations may also occur, leading to preeclampsia and gestational hypertension. The diagnosis and effective management of hypertension during pregnancy is essential to mitigate maternal risks, such as acute kidney injury, stroke, and heart failure, while balancing potential fetal risks, such as growth restriction and preterm birth due to altered uteroplacental perfusion. In the postpartum period, innovative and multidisciplinary care solutions that include postpartum maternal health clinics can help optimize short- and long-term care through enhanced BP management, screening of cardiovascular risk factors, and discussion of lifestyle modifications for cardiovascular disease prevention. As an adjunct to or distinct from postpartum clinics, home BP monitoring programs have been shown to improve BP ascertainment across diverse populations and to lower BP in the months after delivery. Because of concerns about pregnant patients being a vulnerable population for research, there is little evidence from trials examining the diagnosis and treatment of hypertension in pregnant and postpartum individuals. As a result, national and international guidelines differ in their recommendations, and more studies are needed to bolster future guidelines and establish best practices to achieve optimal cardiovascular health during and after pregnancy. Future research should focus on refining treatment thresholds and optimal BP range peripartum and postpartum and evaluating interventions to improve postpartum and long-term maternal cardiovascular outcomes that would advance evidence-based care and improve outcomes worldwide for people with hypertensive disorders of pregnancy.

Keywords: blood pressure; hypertension; postpartum period; pre-eclampsia; pregnancy; telemedicine.

Figure 1.. Expected antepartum and postpartum blood pressure trajectories in a healthy pregnancy.

Figure 2.. Postpartum management timeline after a hypertensive disorder of pregnancy.

BP indicates blood pressure; HBPM, home blood pressure monitoring; HDP, hypertensive disorder of pregnancy; and OB, obstetrician.

Figure 3.. Postpartum hypertension clinic referral methods and models for clinic structure.

EHR indicates electronic health record; HBPM, home blood pressure monitoring; MFM, maternal fetal medicine; and OB, obstetrician.

Figure 4.. Postpartum hypertension clinic activities.

ASCVD indicates atherosclerotic cardiovascular disease; CRP, C-reactive protein; CTA, computed tomography angiography; GAD-7, Generalized Anxiety Disorder–7; PHQ-9, Patient Health Questionnaire–9; and PREVENT, Predicting Risk of Cardiovascular Disease Events.

Figure 5.. Strategies to improve antepartum and postpartum hypertension management.

HDP indicates hypertensive disorders of pregnancy.