Comprehensive Postpartum Management for Women with Hypertensive Disorders of Pregnancy

摘要 妊娠高血压疾病(HDP)--慢性高血压、妊娠期高血压、先兆子痫、 HELLP和子痫-在美国严重的孕产妇发病率和死亡率中占很大一部分。 在黑人患者中发生的频率是非黑人患者的2.5倍。出生后的几周是 这对产妇健康至关重要，特别是考虑到所有与怀孕有关的死亡有一半发生在产后。 美国妇产科医师学会最近重新定义了产后护理 并强调产后患者与初级保健临床医生联系的重要性 来管理慢性疾病。这种移交是至关重要的，因为50%的HDP患者会发展为慢性 高血压和HDP患者日后心血管相关死亡的风险是前者的两倍。与此相一致 根据建议，田纳西州最近将医疗补助覆盖范围扩大到产后12个月。考虑到最大的 产科临床医生目前没有提供全面的初级保健，我们迫切需要桥接的模式 怀孕后护理方面的差距，特别是对医学上易受伤害的病人。虽然干预措施，如 远程医疗和同行导航展示了提高患者护理参与度和减少 产后种族差异，没有随机试验涉及改善产后护理的系统层面的倡议 适用于HDP患者。我们建议为产后病人建立一个全面的管理计划 患有HDP的人有严重孕产妇发病率和死亡率的风险。使用社区参与的方法， 我们将为黑人患者定制这一计划，他们在受艾滋病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部分：1)自我监测血压，2) 血压管理导航，以及3)促进高血压向初级保健临床医生的过渡 管理层。我们的多学科团队，包括母婴医学专家、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 患者参与度，确定产后高血压护理的障碍和促进者，特别是 黑人患者2)进行严格的临床医生参与，揭示产后的障碍和促进者 高血压治疗，以及3)进行一项试点随机试验，比较通常的产后护理和我们的 全面的HDP管理计划。我们假设我们的干预会增加患者的耐心 参与血压监测，识别更多血压范围严重的患者，以及 减少黑人和非黑人患者之间的预后差异。我们的工作直接推进了一体化 在承担不成比例的疾病负担的人群中使用社区参与研究的护理模式 严重的孕产妇发病率和死亡率。结果将产生利益相关者知情的结果和关键 进行稳健的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.