Continued Gaps in Postpartum Follow-Up Care After Complications of Pregnancy 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.

References

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