News from ACOG: Redefining the “Fourth Trimester of Pregnancy” as a Gateway to Long-Term Health

The President’s Program at the opening of ACOG annual conference in Austin, Texas stressed the importance of comprehensive pregnancy care that should extend well beyond the third trimester and labor into period 3 months post-delivery, rightly called as “the fourth trimester”.

Keeping with this year theme of “Medical and Surgical Innovations in Health Care,” the President’s program was not three separate lectures but a ‘President Panel’ that included 3-star speakers discussing “The New Postpartum Visit: Beginning of Lifelong Health.”

Dr. Brown opined that ob-gyns are the primary doctors that most women see for the bulk of care throughout their lives and we must make it sure that we also meet her additional healthcare needs beside pregnancy and gynecology care.

Postpartum care was always in focus throughout Dr. Brown’s tenure as ACOG President. The task force on “Redefining the Postpartum Visit” and ACOG Committee on Obstetric Practice have released a revised “Optimizing Postpartum Care” Committee Opinion published in the May issue of Obstetrics & Gynecology.

ACOG previously recommended that all women should have a comprehensive health check-up visit within the first 6 weeks after birth, now ACOG recommends that post-partum care is an ongoing process and women should stay in contact with their obstetrician or other obstetric care provider for the first three weeks after birth.

This close contact with the obstetrician is especially important for elderly mothers and women with chronic diseases. The initial visits should culminate into a comprehensive individualized post-partum visit at 12 weeks that includes a full assessment of:

• Mood and emotional well-being
• Infant care and feeding
• Physical recovery from birth
• Physical intimacy, spacing and contraception
• Sleep and fatigue
• Chronic disease management
• General health maintenance

Early follow-up is also important for women who had cesarean section, perineal lacerations, lactational difficulties or postpartum depression.

Mothers who had any superimposed medical problems gestational diabetes mellitus or hypertensive disorders or had a preterm labor should undergo special counselling about the increased risk of these disease later in life.

Those women who have had a pregnancy mishap also benefit from early visit in terms of emotional support and counselling and referrals as needed for future risk of such mishap.

It is known that one half of postpartum strokes occur within 10 days of discharge, hence women with hypertensive disorder of pregnancy should have the first follow-up within 7-10 days and those with severe hypertension should be in within 72 hours to evaluate the status of blood pressure.

The postpartum visit at 12 weeks serves as a transition towards the ongoing well-women care. The obstetric care provider should initiate communication with the patients’ primary care provider regarding the medical problems faced by her in pregnancy and the future implications of such problems on the woman’s long-term health.

Currently, about 40% of women do not come for a follow-up visit and important opportunities for contraception counselling and spacing and treatment of chronic health condition is lost.

“New mothers need ongoing care during the ‘fourth trimester.’ We want to replace the one-off checkup at six weeks with a period of sustained, holistic support for growing families,” said Alison Stuebe, M.D., lead author of the Committee Opinion. “Our goal is for every new family to have a comprehensive care plan and a care team that supports the mother’s strengths and addresses her multiple, intersecting needs following birth.”

Dr Brown added “This revised guidance is important because the new recommended structure is intended to consider and cater to the postpartum needs of all women, including those most at risk of falling out of care.”

ACOGconference news release

ACOG newsrelease

Ob/Gyn Updated Facebook page

Hypertensive disorders during pregnancy predisposes to future hypertension and the risk persists for more than 20 years.

Women face substantially high risk of post pregnancy hypertension in the first year after the index pregnancy and the risk persists for more than 20 years, with 14- 32% for the first decade reports the result of a nationwide register based cohort study published in July issue of BMJ.

Nearly one third of women with hypertensive disorder of pregnancy will develop hypertension within 10 years of the affected pregnancy, so blood pressure monitoring should be initiated immediately after delivery.  

What is already known:

Women who have a history of hypertensive disorders while pregnant have 2 to 4-fold increased risk of developing essential hypertension, and a subsequent CV event.

But the data about the timing of developing hypertension and the time at which the screening of these at-risk women should begin is not known.

What the study adds:

This study gives us the chronology of events: How soon the women may develop hypertension, how long the risk will persist after the affected pregnancy and when to start monitoring these women for development of hypertension.

The study identified 482972 women through Danish civil registration system, of these 23235 (4.8%) women developed hypertensive disorder of pregnancy and 16611 developed hypertension during follow-up.

In a cohort of more than one million women delivering in Denmark from 1978-2012, the investigators formed two cohorts and followed them for estimation of cumulative incidence of post-pregnancy hypertension and the other cohort for the estimation of hazard ratios for post-pregnancy hypertension.

Women with chronic hypertension were excluded from the study.

In women who had normotensive first pregnancy in 20s, 30s, or 40s, the cumulative incidences of hypertension in the first 10 years after delivery were 4.0%, 5.7%, and 11.3%, respectively, whereas in women with hypertensive disorder the corresponding incidence were 13.7%, 20.3%, and 32.4%, respectively.

In women with history of hypertensive disorder in most recent pregnancy, the rates of developing hypertension were 12-fold to 25-fold higher in the first-year after delivery and up to 10-fold higher in the coming 10 years.

Women face 2 fold increase risk of developing hypertension, that lasts for the next 20 years, if they have a previous history of hypertensive disorder in pregnancy as compared to women who had normal blood pressure while pregnant.

Why this study is important:

Large cohort, elimination of selection and recall bias.

Data adjusted for age, parity, smoking status, diabetes and BMI.

Immediate post-partum period is very important: The risk of developing hypertension is highest shortly after an affected pregnancy but persists for more than 20 years.

The higher risk of hypertension in a decade after the affected pregnancy also indicates that the etiopathological process causing hypertension in later life, are already at play during the affected pregnancy.

A hypertensive disorder of pregnancy in the second pregnancy was more strongly associated with later hypertension than a hypertensive disorder of pregnancy in the first pregnancy.

Initiation of regular blood pressure assessments should begin soon after a pregnancy complicated by a hypertensive disorder of pregnancy for prompt identification of hypertension in these women.

What is needed in the future:

An algorithm to identify those at greatest risk (the subgroup most likely to benefit from screening) is urgently needed; identification of biomarkers that predict which women will develop hypertension after an affected pregnancy would be very useful.

Quantification of cardiovascular events that can be prevented by early identification of these at-risk women is also needed.

More randomized control trials to form policies on clinical follow up of such women.

Guidelines issued for standardized care to patients with severe hypertension during pregnancy

The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women’s Health Care, has issued a patient safety bundle that assists the healthcare professionals in providing a standardized care to patients with severe hypertension during pregnancy and the postpartum period.

The consensus  bundle was published online  ahead of print in Journal of Obstetrics and Gynecology. The safety bundle is organized into 4 domains and outlines clinical practices that should be practiced at every maternity unit.

The four domains are: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning.

Readiness

The readiness domain consists of 5 key components to prepare each maternity unit for prompt and effective management of women with hypertension in pregnancy. It includes:

Each maternity setting should have standardized criteria for recognizing the warning signs, to diagnose, monitor and treat preeclampsia and eclampsia.

The staff should undergo regular drills to practice the protocols.

The maternity unit, along with the OPD and ER should be well equipped for dealing with patients with severe preeclampsia or eclampsia.

All the medications used in emergency treatment should be readily available and stocked continuously.

Appropriate consultations from various concerned department and means of transportation to tertiary center should be available all the time.

Recognition and Prevention

All women should be educated about the warning signs of hypertension in pregnancy.

Standard protocols should be developed for measuring B.P and urine analysis for all women during pregnancy and postpartum period.

Standard protocols should be developed and followed for investigating all women with hypertension in pregnancy. The investigations should include complete blood count with platelets, aspartate transaminase, and alanine transaminase.

Response (Every Case of Severe Hypertension or Preeclampsia)

Each facility should be well equipped with management of severe hypertension, Eclampsia, seizure prophylaxis, and magnesium over dosage and recognizing symptoms of postpartum hypertension.

The concerned physician or primary care provider should be immediately notified if systolic blood pressure is 160 mm Hg or greater or diastolic blood pressure is 110 mm Hg or greater for two measurements within 15 minutes.

If the second blood pressure reading is also high, treatment should be initiated immediately. Guidelines for initiation and maintenance of Magnesium Sulfate should be readily available everywhere.

Escalation measures should be lined out for patients unresponsive to initial treatment along with follow up and education protocols at 7-14 days postpartum.

Reporting and Systems Learning (Every Unit)

All the members of the multidisciplinary team should receive debriefing about the way the emergency was handled, what went well along with areas of improvement.

The team should also review all other patients admitted with severe hypertension and eclampsia about the outcome. Robust data system should be present to report accurate outcomes to all the concerned persons. The review should include all the measures taken since the woman arrived in emergency room till postpartum education and follow-up.

One very important key element in reducing maternal morbidity and mortality and neonatal morbidity and mortality is time to treatment after the recognition of severe hypertension.

The full text of the article can be accessed here.