Project Summary
The Patient-Centered Outcomes Research Institute (PCORI) partnered with the Agency for Healthcare Research and Quality (AHRQ) to develop a systematic evidence review on the peripartum and postpartum management of women with hypertensive disorders of pregnancy (HDP). PCORI and AHRQ collaborated with the American College of Obstetricians and Gynecologists (ACOG), which planned to develop evidence-based clinical guidance informed by the review.
HDP encompass preeclampsia/eclampsia/HELLP syndrome, gestational hypertension, chronic hypertension, and preeclampsia superimposed on chronic hypertension. A woman can be diagnosed with one of these disorders during pregnancy or the symptoms can emerge de novo in the postpartum period. The number of women experiencing HDP in the United States has risen substantially over the last two decades, currently affecting up to 10 percent of all US pregnancies. Women who experience HDP are at greater risk of morbidity and mortality in the short and long term and this association is more pronounced among women of color. Women with HDP not only have significantly increased risk of pregnancy-related complications but they are also at increased risk of future cardiovascular disease such as chronic hypertension, heart failure, stroke, atrial arrhythmias, coronary heart disease, and mortality. In addition, HDP may also contribute to other pregnancy-related deaths, particularly those caused by cerebrovascular accidents and other cardiovascular conditions which account for about one-quarter of pregnancy-related deaths. The Centers for Disease Control and Prevention reports that about 7 percent of the pregnancy-related deaths between 2014 and 2017 were attributable to HDP.
Although some guidelines highlight the number of women with HDP and the negative consequences of the disorder, there are few, if any, guidelines focused on the management of women with HDP in the peripartum and postpartum periods. Existing guidelines primarily examine management of HDP in the antenatal period and provide limited information about management in the peripartum and postpartum periods. Given the increase in the number of US women with HDP, the significant health consequences, and the lack of evidence synthesis in this area, ACOG is interested in a systematic review of the peripartum and postpartum management of women with HDP.
Key Questions (KQ)
KQ 1: What are the effectiveness, comparative effectiveness, and harms of home blood pressure monitoring/telemonitoring in postpartum individuals?
KQ 2: What are the effectiveness, comparative effectiveness, and harms of pharmacological treatments for hypertensive disorders of pregnancy in postpartum individuals?
KQ 3: What are the comparative effectiveness and harms of alternative magnesium sulfate (MgSO4) treatment regimens to treat preeclampsia with severe features during the peripartum period?
3.a. Are there harms associated with the concomitant use of particular antihypertensive medications during treatment with MgSO4?
For all Key Questions, how do the findings vary by race, ethnicity, HDP subgroup, maternal age, parity, singleton/multiple pregnancies, mode of delivery, co-occurring conditions (e.g., obesity), and social determinants of health (e.g., postpartum insurance coverage, English proficiency, income, educational attainment)?
Contextual Question (CQ)
CQ 1: How are race, ethnicity, and social determinants of health related to disparities associated with incidence of HDP, detection, access to care, management, follow-up care, and clinical outcomes in individuals with postpartum hypertensive disorders of pregnancy?