Clinical Context

Chronic and gestational hypertension, preeclampsia, eclampsia, and other hypertensive disorders of pregnancy are associated with increased risk for future CVD, largely mediated through development of traditional CVD risk factors, including chronic hypertension, diabetes, and obesity.

Women with vs without histories of preeclampsia have twice the CVD risk and 75% increased risk for subsequent CVD mortality. US rates of hypertensive disorders of pregnancy are increasing--nearly doubling from 1993 to 2014--going from 528.9 to 912.4 cases per 10,000 delivery hospitalizations.

Study Synopsis and Perspective

Nearly three quarters of clinicians reported screening patients for hypertensive disorders of pregnancy, but only one quarter comprehensively identified cardiovascular risk, according to survey data from approximately 1,500 clinicians in the United States.

Rates of hypertensive disorders of pregnancy have been on the rise in the United States for the past decade, and women with a history of these disorders require cardiovascular risk monitoring during the postpartum period and beyond, write Nicole D. Ford, PhD, from the Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues. Specifically, the American College of Obstetricians and Gynecologists recommends cardiovascular risk evaluation and lifestyle modification for these individuals, the researchers said.

The most effective management of women with a history of hypertensive disorders of pregnancy will likely involve a team effort by primary care clinicians, obstetrician-gynecologists, and cardiologists, but data on clinician screening and referrals are limited, they added.

In a study published in Obstetrics & Gynecology, the researchers reviewed data from a cross-sectional, web-based survey of clinicians practicing in the United States (Fall DocStyles 2020). The study population of 1,502 respondents with complete surveys included 1,000 primary care physicians, 251 obstetrician-gynecologists, and 251 nurse practitioners or physician assistants. Approximately 60% of the respondents were male, and approximately 65% had been in practice for at least 10 years.

Overall, 73.6% of clinicians reported screening patients for a history of hypertensive disorders of pregnancy. The screening rates were highest among obstetrician-gynecologists (94.8%).

However, although 93.9% of clinicians overall correctly identified at least 1 potential risk associated with hypertensive disorders of pregnancy, only 24.8% correctly identified all cardiovascular risks associated with hypertensive disorders of pregnancy listed in the survey, the researchers noted.

Screening rates ranged from 49.0% to 90.8% for pregnant women, 33.5% to 74.5% for postpartum women, 26.3% to 61.4% for nonpregnant reproductive-age women, 20.3% to 44.6% for perimenopausal or menopausal women, and 1.2% to 4.0% for others outside of these categories.

The barriers to referral most often cited were lack of patient follow-through (51.5%) and patient refusal (33.6%). To improve and facilitate referrals, respondents' most frequent resource request was for more referral options (42.9%), followed by patient education materials (36.2%) and professional guidelines (34.1%).

In a multivariate analysis, primary care physicians were more than 5 times as likely to report not screening patients for hypertensive disorders of pregnancy (adjusted prevalence ratio, 5.54); nurse practitioners and physician assistants were more than 7 times as likely (adjusted prevalence ratio, 7.42).

The researchers also found that clinicians who saw fewer than 80 patients per week were almost twice as likely to not screen for hypertensive disorders of pregnancy than those who saw 110 or more patients per week (adjusted prevalence ratio, 1.81).

"Beyond the immediate postpartum period, there is a lack of clear guidance on [cardiovascular disease (CVD)] evaluation and ongoing monitoring in women with history of hypertensive disorders of pregnancy," the researchers write in their discussion. "Recognizing hypertensive disorders of pregnancy as a risk factor for CVD may allow clinicians to identify women requiring early evaluation and intervention," they add.

The study findings were limited by several factors, including potentially biased estimates of screening practices and the potential for selection bias because of the convenience sample used to recruit survey participants, the researchers noted.

However, the results were strengthened by the inclusion of data from several clinician types and the relatively large sample size, and are consistent with those of previous studies, they said. On the basis of the findings, addressing barriers at both the patient and clinician level and increasing both patient and clinician education about the long-term risks of hypertensive disorders of pregnancy might increase cardiovascular screening and subsequent referrals, they conclude.

"Unfortunately, most CVD risk stratification scores such as the Framingham score do not include pregnancy complications, despite excellent evidence that pregnancy complications increase risk of CVD," said Catherine M. Albright, MD, from the University of Washington, Seattle, in an interview. "This is likely because these scores were developed primarily to screen for CVD risk in men. Given the rising incidence of hypertensive disorders of pregnancy and the clear evidence that this is a risk factor for future CVD, more studies like this one are needed in order to help guide patient and provider education," said Dr Albright, who was not involved in the study.

"It is generally well reported within the [obstetrician-gynecologist] literature about the increased lifetime CVD risk related to hypertensive disorders of pregnancy and we, as [obstetrician-gynecologists], always ask about pregnancy history because of our specialty, which gives us the opportunity to counsel about future risks," she said.

"Women's health [including during pregnancy] has been undervalued and underresearched for a long time," with limited focus on pregnancy-related issues until recently, Dr Albright noted. "This is clear in the attitudes and education of the primary care providers in this study," she said.

A major barrier to screening in clinical practice has been that the standard screening guidelines for CVD (for example, those published by the US Preventive Services Taskforce) have not included pregnancy history, said Dr Albright. "Subsequently, these questions are not asked during routine annual visits," she said. Ideally, "we should be able to leverage the electronic medical record to prompt providers to view a previously recorded pregnancy history or to ask about pregnancy history as a routine part of CVD risk assessment, and, of course, additional education outside of [obstetrician-gynecology] and cardiology is needed," she said.

The clinical takeaway from the current study is that "every annual visit with a person who has been pregnant is an opportunity to ask about and document pregnancy history," Dr Albright said. "After the completion of childbearing, many patients no longer see an [obstetrician-gynecologist], so other providers need to feel comfortable asking about and counseling about risks related to pregnancy complications," she added.

"It is clear that adverse pregnancy outcomes pose lifetime health risks," said Dr Albright. "We will continue to look into the mechanisms of this through research. However, right now the additional research that is needed is to determine the optimal screening and follow-up for patients with a history of hypertensive disorders of pregnancy, as well as to examine how existing CVD-screening algorithms can be modified to include adverse pregnancy outcomes," she emphasized.

The study received no outside funding. The researchers and Dr Albright have disclosed no relevant financial relationships.

Obstet Gynecol. 2022;139(5):898-906.^[1]

Clinical Implications

• Most obstetrician-gynecologists, but only three quarters of clinicians overall, screened patients for history of hypertensive disorders of pregnancy, and only one quarter of clinicians correctly identified all associated cardiovascular risks.
• Strategies to improve evidence-based screening for hypertensive disorders of pregnancy may include increasing clinician awareness, clear clinical guidance, or implementation support.
• Implications for the Health Care Team: Clinicians across the care continuum should collaborate to evaluate risk reduction efforts beyond the postpartum period and ensure counseling regarding future pregnancies for women with hypertensive disorders of pregnancy.

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