Innovation in Postpartum Care for Women With Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy (HDP) affect up to 10% of mother-infant dyads and account
for 7.4% of cases of maternal mortality in the United States. Prompt recognition and
treatment of hypertension remain one of the key features of management of mothers affected by
these conditions. Improving recognition and treatment is of particular importance given that
maternal mortality rates continue to rise in the United States. Moreover, mothers affected by
HDP are at increased risk of long-term morbidity, such as cardiovascular disease,
atherosclerosis, and persistent hypertension outside of pregnancy. Therefore, it is critical
to recognize hypertension throughout maternity care, including in the postpartum period.

The postpartum period is a time of major challenges for the new mother and considerable
physiologic changes that place the new mother at increased risk of adverse events. For a
postpartum woman with a diagnosis of a HDP, the risk of complications extends beyond
discharge from maternity care: up to 41% of severe morbidity and mortality from HDP occurs
after 48 hours postpartum, as postpartum blood pressures tend to peak 3-6 days after birth.
For these reasons, the American College of Obstetricians and Gynecologists (ACOG) and the
National Partnership for Maternal Safety recommend early postpartum follow-up for women
diagnosed with HDP, in the form of blood pressure (BP) evaluation by a health care provider
at 7-10 days postpartum. However, barriers to follow-up, including childcare arrangements,
transportation access, and recovery from delivery, limit mothers' ability to adhere to this
recommended in-office follow-up. Indeed, attendance at postpartum follow-up visits is poor
and reflects significant disparities.

A potential alternative to in-office evaluation is at-home blood pressure (BP) monitoring.
At-home BP monitoring is a novel, affordable method to empower, educate, and engage
postpartum women affected by HDP. This approach is not in widespread use in the US, despite
the American Heart Association indicating that home BP monitoring is recommended for all
people with high blood pressure. Within the obstetric population, pilot studies have
demonstrated the feasibility and acceptability of remote BP monitoring. However, a randomized
trial of postpartum at-home BP monitoring compared with office-based follow-up is lacking.

Inclusion Criteria:

- Age 18-60 years

- Diagnosis of a hypertensive disorder of pregnancy (HDP)

- Chronic hypertension requiring medications

Exclusion Criteria:

- Less than 18 years or older than 60 years

- No access to cellular telephone

- Chronic hypertension not on medications during pregnancy or postpartum

- No diagnosis of HDP

- Upper arm circumference < 9 inches or > 17 inches

- Incarcerated mother

- The woman requires a 1-week postpartum in-office visit for other medical reason
unrelated to the diagnosis of hypertensive disorder of pregnancy