Race Differences in Blood Pressure Trajectory After Delivery-A Window Into Opportunities to Decrease Racial Disparities in Maternal Morbidity and Mortality

Adi Hirshberg
2020 JAMA Network Open  
In a prospective cohort study, Hauspurg et al 1 described blood pressure trajectories during the first 6 weeks post partum among more than 1000 women with hypertensive disorders of pregnancy and assessed differences in these trends by self-reported race. Using blood pressure data obtained through a postdischarge remote blood pressure monitoring program, investigators observed a decline of 6.3 mm Hg per week for systolic blood pressure and 3.4 mm Hg per week for diastolic blood pressure in the
more » ... rst 3 weeks after delivery, with stabilization thereafter. More than 70% of women had stage 1 or 2 hypertension at 6 weeks post partum. With respect to racial differences, non-Hispanic Black women had a slower decline in blood pressure and higher rates of persistent hypertension 6 weeks post partum compared with White women (126 of 185 [68.1%] vs 393 of 764 [51.4%]; P < .001). The incidence of postpartum hospital readmission was also higher among non-Hispanic Black women compared with White women during this time period (36 of 213 [16.9%] vs 76 of 804 [9.5%]; P = .02). The rate of maternal mortality is higher in the United States than in all other developed countries, and the trajectory is heading in the wrong direction. Hypertension is a leading cause of maternal morbidity and mortality as well as obstetrical readmissions. 2 Racial disparities in maternal mortality and preeclampsia are well established, with non-Hispanic Black women carrying 3-to 4-fold greater risk of dying from pregnancy-related causes. 3 They are also more likely to develop preeclampsia and associated complications, such as cardiac arrest, heart failure, and death. Historic research examining hypertensive disorders of pregnancy has focused on antenatal prevention and intrapartum management. Delivery was previously considered a cure; however, recent data reveal that a subset of women have persistent hypertension. Contemporary studies have shifted focus to the long-term cardiac sequelae after a pregnancy complicated by preeclampsia, with published literature recently identifying associations between preeclampsia and future risk of cardiovascular disease and stroke. 4 Our rudimentary understanding of blood pressure trajectories post partum and following hospital discharge has limited the development of best practices for postpartum surveillance, management, and counseling. Due to brief postpartum hospitalizations, often single blood pressure checks 3 to 10 days post partum as recommended by the American College of Obstetricians and Gynecologists, 5 and poorly attended postpartum visits, longitudinal trends in blood pressure after delivery have been difficult to study. This study 1 sheds valuable light on both short-and long-term hypertension resolution using multiple blood pressure values obtained through their remote monitoring program. A more sophisticated understanding of factors that confer increased risk of persistent hypertension is critical, as nearly 70% of maternal deaths associated with hypertensive disorders occur post partum, some of which occur after 6 weeks. 6 From a practical perspective, this study 1 contributes to existing literature by identifying patients who may be at higher risk of postpartum morbidity, thereby providing potential opportunity to target and aggressively treat pregnancyrelated hypertension in non-Hispanic Black women after delivery with the goal of mitigating disparities in immediate postpartum outcomes as well as in long-term health. The fitted blood pressure trajectories stratified by race during the first 6 weeks post partum (Figure 2 in Hauspurg et al 1 ) suggest that non-Hispanic Black women were discharged home with higher systolic and diastolic blood pressures and had similar declines from initial values, raising questions as to whether +
doi:10.1001/jamanetworkopen.2020.31122 pmid:33351081 fatcat:p7p3ltby2fdqbkaijzrqjyfa5i