Factors associated with postpartum initiation of anti-hypertensive medication after hospital discharge among individuals with hypertensive disorders of pregnancy in a remote monitoring program

Abstract

Abstract Importance Following a hypertensive disorder of pregnancy, hypertension can worsen in the postpartum period following hospital discharge. Risk factors for hypertension exacerbation and associated outcomes have not been well characterized. Objective We sought to identify risk factors and characterize outcomes for individuals requiring initiation of anti-hypertensive medication following hospital discharge postpartum through our hospital system’s remote blood pressure management program. Design We performed a cohort study of individuals delivered between 9/2019-6/2021 and enrolled in our remote blood pressure monitoring program, which utilizes standardized protocols for anti-hypertensive medication initiation postpartum. Setting Postpartum unit at a referral hospital Participants Population-based sample of individuals with a hypertensive disorder of pregnancy (HDP, preeclampsia or gestational hypertension) and no pre-pregnancy hypertension. Exposure Anti-hypertensive medication initiation timing: no anti-hypertensive medications, initiation prior to hospital discharge postpartum, and initiation after hospital discharge postpartum Main outcomes Postpartum readmission and emergency room visits Results Of 2,705 individuals in our cohort, 1,458 (54%) required no anti-hypertensive medications postpartum, 637 individuals (24%) were discharged on anti-hypertensive medications, and 610 (23%) required initiation of anti-hypertensive agents after discharge. Utilizing an inpatient threshold of ≥ 150/100 mmHg in line with current obstetric guidelines for medication initiation postpartum fails to identify 385 (63%) of individuals who required medication initiation after discharge. These individuals had higher home blood pressures, increased odds of Emergency Room visits [aOR 2.22 (95%CI 1.65–2.98)] and hospital readmissions postpartum [aOR 5.73 (95%CI 3.72–8.82)] compared with individuals discharged on no medications. Conclusions and Relevance Over 20% of individuals with hypertensive disorders of pregnancy required initiation of anti-hypertensive medications after hospital discharge. Current blood pressure guidelines for medication initiation fail to identify the majority of these individuals during delivery hospitalization. These data support the critical role of remote blood pressure monitoring programs and highlight the need for improved tools for risk stratification and liberalization of thresholds for medication initiation postpartum.