Comprehensive Postpartum Management for Women with Hypertensive Disorders of Pregnancy

总结 妊娠期高血压疾病（HDP）-慢性高血压、妊娠期高血压、先兆子痫， HELLP和子痫-占美国严重孕产妇发病率和死亡率的很大一部分。 黑人患者的发病率是非黑人患者的2.5倍。出生后的几周是 这对孕产妇健康至关重要，特别是考虑到一半的妊娠相关死亡发生在产后。 美国妇产科学院最近重新定义了产后护理， 出生后12个月，并强调将产后患者与初级保健医生联系起来的重要性 来管理慢性疾病这种交接是至关重要的，因为50%的HDP患者发展为慢性 高血压患者的心血管相关死亡风险是高血压患者的两倍。根据这一 田纳西州最近将医疗补助覆盖范围扩大到产后12个月。鉴于大多数 产科临床医生目前不提供全面的初级保健，我们迫切需要模型的桥梁 怀孕后的护理差距，特别是对医学上脆弱的病人。虽然干预措施，如 远程医疗和同伴导航显示出改善患者参与护理和减少 产后种族差异，没有随机试验解决系统层面的举措，以改善产后护理 对于HDP患者。我们建议为产后病人建立一个全面的管理方案 患有HDP的妇女面临严重的孕产妇发病率和死亡率风险。采用社区参与的方法， 我们将为黑人患者量身定制这一计划，他们在受影响的患者中所占比例不成比例。 产后HDP。该计划强调三个关键组成部分：1）自我监测血压，2） 血压管理导航，以及3）促进了向初级保健临床医生治疗高血压的过渡 管理我们的多学科团队，包括母胎医学专家，注册护士 助产士，项目导航员和社会工作者将实现我们的具体目标：1）进行严格的 患者参与，确定产后高血压护理的障碍和促进因素，特别是在 黑人患者2）进行严格的临床医生参与，揭示产后障碍和促进因素 高血压管理，以及3）进行一项试点随机试验，比较常规产后护理与我们的 全面的HDP管理计划。我们假设我们的干预会增加病人 参与血压监测，发现更多血压范围严重的患者， 减少黑人和非黑人患者之间的结果差异。我们的工作直接推进综合 利用社区参与的研究，在承受不成比例的医疗负担的人群中建立护理模式， 产妇发病率和死亡率很高。结果将产生知情的结果和关键 进行稳健多中心试验的参数估计。

SUMMARY Hypertensive disorders of pregnancy (HDP) - chronic hypertension, gestational hypertension, preeclampsia, HELLP, and eclampsia - account for a substantial portion of severe maternal morbidity and mortality in the U.S. and occur 2.5 times more frequently among Black compared to non-Black patients. The weeks after birth are crucial for maternal health, especially considering that half of all pregnancy-related deaths occur postpartum. The American College of Obstetricians and Gynecologists recently redefined postpartum care to encompass 12 months after birth and stressed the importance of connecting postpartum patients to primary care clinicians to manage chronic medical conditions. This handoff is critical as 50% of patients with HDP develop chronic hypertension, and patients with HDP have twice the risk of later cardiovascular-related death. In line with this recommendation, Tennessee recently expanded Medicaid coverage to 12 months postpartum. Given that most obstetric clinicians currently do not provide comprehensive primary care, we urgently need models for bridging gaps in care after pregnancy especially for medically vulnerable patients. While interventions such as telemedicine and peer navigation demonstrate promise to improve patient engagement in care and reduce postpartum racial disparities, no randomized trials address system-level initiatives to improve postpartum care for patients with HDP. We propose to build a comprehensive management program for postpartum patients with HDP who are at risk of severe maternal morbidity and mortality. Using a community-engaged approach, we will tailor this program to Black patients who represent a disproportionate share of those affected by postpartum HDP. This program emphasizes three key components: 1) self-monitoring of blood pressures, 2) blood pressure management navigation, and 3) facilitated transition to primary care clinicians for hypertension management. Our multidisciplinary team, including maternal-fetal medicine specialists, certified nurse midwives, program navigators, and social workers will accomplish our specific aims to: 1) conduct rigorous patient engagement that identifies barriers and facilitators to postpartum hypertension care especially among Black patients 2) conduct rigorous clinician engagement that uncovers barriers and facilitators to postpartum hypertension management, and 3) perform a pilot randomized trial comparing usual postpartum care to our comprehensive HDP management program. We hypothesize that our intervention will increase patient engagement with blood pressure monitoring, identify more patients with severe-range blood pressures, and reduce disparities in outcomes between Black and non-Black patients. Our work directly advances integrated models of care using community-engaged research among populations who bear a disproportionate burden of severe maternal morbidity and mortality. The results will produce stakeholder-informed outcomes and key parameter estimates for conducting a robust multicenter trial.