Q&A: Preeclampsia follow-up program urges women to be proactive in CVD prevention
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Key takeaways:
- Postpartum program urges women with preeclampsia history to attend follow-up visits with OB/GYNs, PCPs and cardiologists.
- The program has led to more women discussing CVD risk factors with health care providers.
Preeclampsia significantly increases future risk for CVD; however, many women with preeclampsia fail to attend postpartum follow-up visits and, therefore, do not receive proper preventive care.
“Hypertensive disorders of pregnancy, including preeclampsia, occur in about 8% of women. The prevalence continues to increase as [many pregnant women] are older and have underlying medical complications such as obesity,” Kelley D. Clark, MD, chair of obstetrics and gynecology, maternal-fetal medicine specialist and medical director of perinatal medicine at WellSpan York Hospital and co-developer of the Postpartum Preeclampsia Follow-up Program at WellSpan, told Healio. “For the mom, it’s a multiorgan system disease and the cure is delivery.”
WellSpan launched the Postpartum Preeclampsia Follow-up Program to provide proper follow-up care to women in the early postpartum period and, ultimately, prevent future CVD.
“We want to make sure that women with preeclampsia are not lost in the system. We want to make sure that there is this bridge between OB/GYN to [primary care] and, if necessary, with cardiology,” Samantha Stover, BSN, RN, heart health program coordinator at WellSpan and adjunct professor at York College, told Healio. “Also, knowing that these women may have future pregnancies, and to already have that trusted relationship with a PCP or cardiologist, makes it a little less stressful for these women.”
Healio spoke with Clark and Stover about the risks of preeclampsia and the goals of WellSpan’s Postpartum Preeclampsia Follow-up Program.
Healio: What diseases are women with preeclampsia at risk for?
Clark: The leading cause of death in women is heart disease, yet it is still not recognized as readily as it is in men. Patients with a history of hypertensive disorders of pregnancy, whether gestational hypertension or preeclampsia, have an almost 20% risk for developing a CV event within a decade of delivery. The earlier and/or more severe their hypertensive disorder, the higher the risk for CV events. The more severe the blood pressure complication and the earlier it is in pregnancy, particularly in those less than 34 weeks [gestation], the higher their risk for having a significant CV event.
Healio: Why was WellSpan’s Postpartum Preeclampsia Follow-up Program formed?
Stover: We launched this program back in 2021. We did multiple literature reviews to determine how to best approach preeclampsia follow-up care and to make sure we would make an impact. We wanted to make sure we identified knowledge gaps in preeclampsia follow-up care because, although 2013 was when people began to say preeclampsia is a risk factor for heart disease, it wasn’t until more recently that such programs started to develop. In May 2021, we launched the first phase and built a registry to tie all women across WellSpan’s five birthing facilities together. Every week I can go in and see who falls on that list based on different codes under the hypertensive disorders of pregnancy bridge, so these women can be reached out to individually. The program has gone through multiple phases, and it will continue to grow.
It’s not always easy for the mom to come in for postpartum follow-up. Research shows that fewer than half of women don’t go to their 6-week follow-up appointment, let alone see a PCP within the year. We want this program outreach to go to these women. We want them to go to that 6-week appointment and build that bridge to their PCP so care is not missed and the primary care aspect isn’t falling on the OB/GYN. When and if they go in for follow-up, the PCP is notified and, if they don’t have a PCP, we give them the opportunity to obtain one using the program’s referral line. When I do chart reviews, I see that these women meet with their OB/GYN at the 6th week, and the OB/GYN gives them the referral to get a PCP so care can continue. The goal is to fill the knowledge gaps and build the bridge from the OB/GYN to the PCP to have follow-up primary preventive measures in place to prevent future CVD events.
Many CV screening tools will not identify women at high risk because they’re young and all they have is a history of preeclampsia and not many other risk factors. That’s why early follow-up care is important.
Since we started our outreach, we have reached close to 3,000 women in this specific registry.
Clark: Provider education is also important. Almost 40% of health care providers are not aware that having a hypertensive disorder in pregnancy increases CVD risk. It’s something that came out in cardiology literature before it started being pushed in obstetrical literature. This program has been a great opportunity to educate our providers in the community.
Healio: What are the goals of this program and how does it work for patients?
Clark: The goal is to be proactive in CVD prevention for women who have a history of BP complications from pregnancy. Twenty percent of women with preeclampsia are not just at risk but are going to have some future CV event. By identifying them and getting them into care, we can modify risk factors like obesity, manage chronic hypertension, manage lipids — all things to decrease risk for a significant CV event, such as myocardial infarction, occlusion of arteries or stroke.
Stover: Within the five birthing facilities at WellSpan, we developed a registry where there is an ICD or diagnosis code that pulls women into this list. At about 3 weeks postpartum, I go in and pull those who delivered that specific week, and send them an outreach letter through MyWellSpan, which is our electronic health record. Fortunately, there is a huge participation rate in MyWellSpan, so the outreach has been very successful. About 92% of the women that get this letter open it and read it. Once they receive the letter, ideally, they should be at their 6-week OB/GYN appointment and, if they have questions, they’re able to ask their obstetrician and say, “I got this letter that says I have these risk factors, what should I do?” The obstetrician can then say, “You need to follow-up with your PCP,” or, if they already have one, a lot of times the PCP receives a letter as well. That letter will reach out to the patient and encourage them to come in within a 3-to-6-month timeframe to further talk about these modifiable risk factors.
Healio: Are there any ongoing projects?
Stover: One of the most recent phases we rolled out with this program is a cardiology referral system. The PCP can refer patients to one of our five cardiologists that have been deemed champions for those areas based on where the women live. This high-risk population for which we encourage a referral to cardiology comprises about 10% of patients. The referral system can help outline their appointment and long term care. The American College of Cardiology has said that people who have preeclampsia should be seen by a cardiologist by the age of 45. We’re ahead of that. We do have some women in their 40s to mid-40s that deliver, but most of the women we see are younger than 45. To have a relationship with a cardiologist and already have a care plan before the age of 45 is a tremendous opportunity to make changes. Before we started this program, 16% of patients saw a PCP and discussed CV risk factors. A year after the program was launched, we did chart reviews and we were up to 26%, which we considered a huge success. Knowing that we’re doing this early on not only helps the mom but, hopefully, the measures they adapt and habits they create can work its way down to the baby. Maybe one day heart disease won’t be the No. 1 killer of women.
We also want to work on speeding up the referral process because by the time they have their 6-week checkup, then go to their PCP and then see cardiology, potentially, a year later, a lot of things could have happened in that timeframe.
Dr. Clark is also working on a pilot program for WellSpan Remote Patient Monitoring, a project for women with preeclampsia with severe features to monitor BP. At about 36 weeks of pregnancy, women will go home with a BP machine. We want them to understand how to take their BP, when to take BP and make it part of their daily routine. When the patient uses the BP cuff, the data will automatically go into the health record via Bluetooth for real-time analysis of BP levels to identify if a woman need to be seen sooner or later. From there, the patient will have daily follow-up. Getting a BP cuff in women’s hands is going to be a huge help to be able to trend these numbers.
Clark: As part of the BP program, women will be sent home with a calibrated Bluetooth electronic cuff that will feed directly into a flow sheet into the electronic health record. You don’t have to worry as much about whether the patient took their BP correctly, if the cuff was the right size, if they let the cuff down like they should, if they read the numbers right, etc. Five days a week somebody will reach out to them directly about preeclampsia symptoms and BP levels. It may also be an opportunity to stay on top of other postpartum issues like postpartum depression.