QI program linked to increased early readmissions for postpartum preeclampsia

A quality improvement (QI) program can lead to increased and earlier readmission for postpartum preeclampsia, according to a recent study in JAMA Network Open.¹

A maternal death caused by a hypertensive disorder of pregnancy (HDP) occurs once every 10 days in the United States. Of these deaths, 40% occur within 6 weeks postpartum. Additionally, postpartum hypertension is the leading cause of severe maternal morbidity, and rates have significantly increased over time.

From 2010 to 2021, an increase in chronic hypertension from 1.2% to 2.7% was reported.² The rate of gestational diabetes also increased from 0.7% to 1.1%. Overall, a 5% increase in HDPs was reported.

Data about hypertensive disorders in the postpartum period is currently lacking.¹ Patients are often not seen until 2 weeks postpartum following a cesarean delivery and 4 to 6 weeks following vaginal delivery, and stressors may lead patients to cancel their appointments.

Investigators developed a QI program to optimize outcomes of earlier and more frequent health care encounters and assess maternal blood pressure (BP) and HDP symptoms. A study was conducted to evaluate the efficacy of the QI program.

The QI program was conducted at a pediatric clinic in an academic medical center. A preintervention cohort was created for biological mothers and their newborns visiting the clinic from December 2017 to December 2018. The postintervention cohort included those visiting the clinic for the next 10 consecutive months.

Participants included patients delivering at the academic medical center and having their newborn evaluated at the pediatric clinic. Exclusion criteria included delivering outside the clinic and not being the birth mother.

BP was collected using a semiautomated BP cuff based on accepted BP detection criteria. A second BP measurement would occur after 5 minutes for algorithm recommendations if the first measurement was a systolic BP of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher.

Preeclampsia symptoms including headache, scotomata, right upper quadrant pain, and shortness of breath were also assessed. Participants with mild-range BP, preeclampsia symptoms, or severe-range BP were sent to the obstetrics emergency department (OB-ED).

The clinic’s follow-up schedule included a 7- to 10-day postpartum follow-up BP assessment for patients with HDP. Patients with cesarean delivery received a 2-week follow-up, and all mothers received follow-up at 4 to 6 weeks postpartum.

Electronic medical records were evaluated for data on BP at the newborn visit, maternal symptoms, demographics, delivery, and readmission. Readmission because of preeclampsia within 2 months following delivery was reported as the primary outcome of the analysis.

HDP was determined based on American College of Obstetricians and Gynecologists guidelines. New-onset hypertension and proteinuria indicated preeclampsia without severe features, while gestational hypertension used the same BP criteria as preeclampsia but without proteinuria. Preeclampsia with severe features was defined as new-onset hypertension or severe hypertension.

There were 595 individuals in the preintervention cohort and 565 in the postintervention cohort, aged a mean 27.2 and 27 years, respectively. Maternal demographic did not significantly differ between groups. Overall, public insurance was reported in 79% of participants and 77% were from racial and ethnic minority groups.

Readmission because of postpartum preeclampsia was reported in 42 patients, 50% of whom had de novo postpartum preeclampsia. Of OB-ED visits, 33 were recommended in the QI program, leading to postpartum preeclampsia readmission in 88% of individuals.

The QI postintervention cohort had a significantly higher postpartum preeclampsia readmission rate than the preintervention cohort, at 29 of 565 individuals vs 13 of 595 individuals, respectively. Among readmitted patients, those in the postintervention group were more often Black than those in the preintervention group.

In the preintervention cohort, 3 of 13 individuals did not list preeclampsia as their primary reason for OB-ED presentation, vs 2 of 29 in the postintervention cohort. Being symptomatic was more common in the preintervention cohort, with headache being the most common symptom.

These results indicated an increase in readmission for postpartum preeclampsia at an earlier timeframe from a QI intervention. Investigators recommended additional research to verify the efficacy of this method.

References

1. Amro FH, Smith KC, Hashmi SS, et al. Well-Child Visits for Early Detection and Management of Maternal Postpartum Hypertensive Disorders. JAMA Netw Open. 2024;7(6):e2416844. doi:10.1001/jamanetworkopen.2024.16844
2. Krewson C. Rising prevalence of hypertensive disorders of pregnancy reported. Contemporary OB/GYN. June 10, 2024. Accessed June 13, 2024. https://www.contemporaryobgyn.net/view/rising-prevalence-of-hypertensive-disorders-of-pregnancy-reported