Continued Gaps in Postpartum Follow-Up Care after Complications of Pregnancy that Increase CVD Risk
Pregnancy is now recognized as a cardiometabolic stress test. This means that the development of a pregnancy complication, such as gestational diabetes mellitus (GDM), hypertensive disorder of pregnancy (HDP), or preterm delivery reveals evolving risk for maternal development of cardiovascular diseases and type 2 diabetes.1 Further, intrauterine exposure to these pregnancy complications is linked to increased risk of offspring cardiometabolic risk and disease in adulthood.2 This underscores the importance of implementing preventive interventions and proactive pre-conceptual, antenatal, and postpartum care in childbearing women who are at greatest risk.
In the United States (U.S.), those who are at greatest risk for developing these pregnancy complications and long-term cardiometabolic disease are women of color, particularly African American or black, American Indian, Alaska Native, and Latina women, as well as low-income women.3-7 Opportunities abound for the development of team-based approaches to improving women’s “cardio-obstetric” care, an emerging field in women’s health. One major challenge in the current U.S. health care delivery system is to coordinate childbearing women’s health care, and postpartum follow-up care in particular, in such a way that women are effectively engaged in prevention early in the life course.
In 2011, the American Heart Association and American College of Cardiology issued a joint practice guideline for CVD prevention in women that emphasized the need for postpartum follow-up care after GDM, HDP, and preterm labor.8 Specific U.S. guidelines for postpartum screening following GDM include those issued by the American Diabetes Association and the American College of Obstetricians and Gynecologists (ACOG) and indicate that glucose screening occurs between 4 and 12 weeks after delivery.9, 10 Specific U.S. guidelines for postpartum screening for HDP, from ACOG, indicate that blood pressure be monitored in the hospital (or with an equivalent level of outpatient surveillance) for 72 hours after birth and checked again at 7 to 10 days postpartum (or sooner if a woman is symptomatic).11 Ongoing follow-up and blood pressure screening are recommended to continue at the 6-week postpartum and subsequent visits.
A 2019 systematic review revealed that significant gaps persist in postpartum follow-up care and screening among women with GDM and HDP.12 The review included nine observational studies in which postpartum visits and/or screening rates were measured among U.S. women following GDM and/or HDP. The postpartum screening rate for diabetes did not exceed 58% by four months postpartum across the studies analyzed, indicating suboptimal improvement in adherence to the guidelines in the past ten years.12 Among women with HDP, blood measure measurement appeared to take place routinely in the postpartum period, but it was unclear whether follow-up intervention occurred when warranted. This review underscores that postpartum risk factor screening in childbearing women at greatest risk for developing cardiometabolic disease remains suboptimal and varies substantially.12 Cardiovascular nurses and advanced practice nurses play an important role as advocates for preventive care in this high-risk population.
- Ferranti EP, Jones EJ and Hernandez TL. Pregnancy Reveals Evolving Risk for Cardiometabolic Disease in Women. J Obstet Gynecol Neonatal Nurs. 2016;45:413-25.
- Barker DJ and Thornburg KL. The obstetric origins of health for a lifetime. Clin Obstet Gynecol. 2013;56:511-9.
- AS, Haas JS, McElrath TF and McCormick MC. Predictors of compliance with the postpartum visit among women living in healthy start project areas. Matern Child Health J. 2006;10:511-6.
- Zhang S, Cardarelli K, Shim R, Ye J, Booker KL and Rust G. Racial disparities in economic and clinical outcomes of pregnancy among Medicaid recipients. Matern Child Health J. 2013;17:1518-25.
- Kim C, Newton KM and Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care. 2002;25:1862-8.
- Manuck TA. Racial and ethnic differences in preterm birth: A complex, multifactorial problem. Semin Perinatol. 2017;41:511-518.
- Xiang AH, Li BH, Black MH, Sacks DA, Buchanan TA, Jacobsen SJ and Lawrence JM. Racial and ethnic disparities in diabetes risk after gestational diabetes mellitus. Diabetologia. 2011;54:3016-21.
- Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Pina IL, Roger VL, Shaw LJ, Zhao D, Beckie TM, Bushnell C, D’Armiento J, Kris-Etherton PM, Fang J, Ganiats TG, Gomes AS, Gracia CR, Haan CK, Jackson EA, Judelson DR, Kelepouris E, Lavie CJ, Moore A, Nussmeier NA, Ofili E, Oparil S, Ouyang P, Pinn VW, Sherif K, Smith SC, Jr., Sopko G, Chandra-Strobos N, Urbina EM, Vaccarino V and Wenger NK. Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the american heart association. Circulation. 2011;123:1243-62.
- ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstet Gynecol. 2018;131:e140-e150.
- American Diabetes A. 13. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018;41:S137-S143.
- American College of O, Gynecologists and Task Force on Hypertension in P. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122:1122-31.
- Jones EJ, Hernandez TL, Edmonds JK and Ferranti EP. Continued Disparities in Postpartum Follow-Up and Screening Among Women With Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review. J Perinat Neonatal Nurs. 2019;33:136-148.