Risultati per: Linee guida sull’emorragia postpartum

This article in the Women’s Health series discusses recent increases in US maternal death rates, disparities in rates by race and ethnicity, poor cardiovascular health (CVH) as one of the multifactorial causes, and clinical approaches to assessing and treating poor CVH postpartum.

Circulation, Volume 148, Issue Suppl_1, Page A15628-A15628, November 6, 2023. Introduction:Insufficient maternal care in the postpartum period (PP) has resulted in significant maternal morbidity and mortality in the U.S., most commonly due to cardiovascular (CV) disease. Digital health technologies have been proposed as a potential solution to eliminate barriers to maternal CV care. In this context we performed a systematic review to determine the benefit of digital health interventions designed to improve postpartum CV health.Methods:We conducted a systematic review of PubMed/MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library. We included studies if the study population included PP women, and an intervention that involved digital or mobile health (including wearable devices, telemedicine, or remote monitoring). We only included studies that measured an outcome related to CV health. Two independent reviewers screened all studies and a third independent reviewer resolved any conflicts.Results:Our initial search identified 1448 studies. After removal of 143 duplicates, 1305 abstracts were screened of which 51 full studies were assessed for eligibility. Of these, 17 met inclusion/exclusion criteria. Studies were categorized into 3 broad CV outcomes: blood pressure (BP), physical activity (PA), and diet/weight loss. The majority of remote BP monitoring programs paired with telemonitoring (N=5 studies) were successful in optimizing BP, and increasing likelihood of BP measurement within 10 days PP. Interventions aimed at increasing PP physical activity included mobile applications, text-based coaching, and wearable devices such as pedometer and FitBit (N=9 studies). Just over half of these studies showed no change in PA, while the other half showed modest benefit at increasing daily or weekly PA. Weight loss interventions included smartphone applications, interactive websites, or text-based coaching (N=6 studies). Most of these studies showed a modest benefit in terms of lowered caloric intake and/or weight loss up to 1 year PP.Conclusions:The majority of studies we reviewed found that digital health interventions such as mobile health, telemonitoring and wearable devices were effective at improving postpartum CV health in the postpartum period.

Circulation, Volume 148, Issue Suppl_1, Page A12289-A12289, November 6, 2023. A 44-year-old G3P1011 underwent uncomplicated Caesarian section for obstetric indications with delivery of a healthy girl. Several hours postpartum, she developed hypoxemia requiring transient supplemental oxygen. Cardiology was consulted for further evaluation.Upon initial assessment, she appeared comfortable with an oxygen saturation of 93% on room air. She reports an otherwise uneventful pregnancy. Her past medical history is significant for chronic hypertension on propranolol. She was afebrile with a HR of 91, BP 147/66 (left arm) and 155/68 (right arm). Her JVP was 10-11 cm H20. There was a III/IV low-pitched decrescendo early-mid diastolic murmur, loudest at the left lower sternal border, radiating to the apex, and a systolic ejection murmur. EKG (panel A) showed normal sinus rhythm, with no ischemic abnormalities.Due to the discovery of a new murmur, there was concern for valvular pathology as a cause for her suspected heart failure, particularly aortic regurgitation (AR). An urgent TTE (panel C-E) was requested and showed a dissection flap in the ascending aorta, effacement of the sinotubular junction, and severe AR. CT angiogram confirmed the diagnosis of type A aortic dissection (AD; panel B).Twelve hours after the delivery of her baby, she underwent emergent aortic valve repair and aortic arch replacement. She recovered well and was discharged home post-op day 6. Though no human data exists, animal data suggests increased AD risk in breastfeeding animals with Marfan Syndrome. Due to her near catastrophic presentation, she elected to not breastfeed. Her genetic testing results are pending.AD in pregnancy is rare. There is an increased risk of AD in pregnant compared to non-pregnant women. AD often occurs in the third trimester or postpartum, and most women are unaware of a preexisting arteriopathy. In this case, the detection of a diastolic murmur resulted in rapid diagnosis and treatment, essential in the management of this life-threatening condition.

Circulation, Volume 148, Issue Suppl_1, Page A17351-A17351, November 6, 2023. Introduction:Postpartum hypertension is a leading cause of racial inequities in maternal morbidity and mortality.Research Question:Is racial-economic segregation, a proxy for structural racism, associated with differences in postpartum blood pressure (BP) in Black, Hispanic and Asian (“Global Majority”) birthing people?Methods:We used data (n=369) from the coronaVirus Impact on Birth Equity (VIBE) Study, a prospective cohort in Philadelphia and New York City, 2022-2023. We measured racial-economic segregation by the Index of the Concentration of Extremes (ICE) using zipcode. Participants completed the Gendered Racial Microagressions (GRM) in Obstetrics Scale, and reported postpartum BPs through a text-messaging platform for 90 days. We used mixed-effects linear regression with repeated measures to estimate associations between ICE and postpartum systolic and diastolic BP (SBP, DBP). We adjusted for prepregnancy BMI, race-ethnicity, age, parity, and prepregnancy hypertension. We tested effect modification by hypertensive disorders of pregnancy (HDP) and GRM.Results:Participants were 10.3% Asian, 38.0% non-Hispanic Black, 38.2% Hispanic, and 13.6% other; 26.0% had HDP, 70.7% lived in high concentration poor, Black neighborhoods (highest quartile of ICE), and 37.6% experienced GRM. People in poor, Black neighborhoods had a higher 90-day postpartum mean SBP (120.6 mmHg) than those in other neighborhoods (116.4 mmHg, difference (β)=4.2, 95% confidence interval(CI)=1.7, 6.8; adjusted difference (aβ) = 2.1, 95% CI=0, 4.2). DBP did not differ (73.8 vs. 73.1 mmHg, β =0.8, 95%CI=-1.1, 2.6; aβ=0.1, 95% CI=-1.9, 1.6). Associations did not vary by HDP but were heightened for participants in poor, Black neighborhoods who experienced GRM vs. those in other neighborhoods who did not experience GRM (SBP: β = 6.2, 95%CI= 2.8, 9.6; aβ = 4.2, 95%CI = 1.3, 7.1; DBP: β = 2.1, 95%CI= 0.5, 4.7; aβ = 1.1, 95%CI = -1.3, 3.6).Conclusions:Racial-economic segregation is associated with higher postpartum BP over a 90-day period in Global Majority people, and further heightened in those who experienced GRM. Interventions to disrupt structural racism, including segregation, and eliminate GRM in obstetric care may improve postpartum health inequities.

Circulation, Volume 148, Issue Suppl_1, Page A14790-A14790, November 6, 2023. Introduction:To determine whether neighborhood socioeconomic disadvantage as measured by the Area Deprivation Index (ADI) in early pregnancy is associated with higher 30-year predicted risk of cardiovascular disease (CVD) by the Framingham Risk Score.Methods:A secondary analysis of data from the prospective Nulliparous Pregnancy Outcomes Study-Monitoring Mothers-to-Be (nuMoM2b) Heart Health Study (HHS) longitudinal cohort. Participant home addresses in the first trimester were geocoded at the census-tract level. The exposure was neighborhood socioeconomic disadvantage using the 2015 ADI by tertile (least deprived [T1], reference; most deprived [T3]). The primary outcome was the predicted 30-year risk of hard CVD using the Framingham Risk Score (composite of fatal and non-fatal coronary heart disease and stroke). The secondary outcome was predicted 30-year risk of total CVD (composite of “hard” CVD plus coronary insufficiency and angina pectoris, stroke, transient ischemic attack, intermittent claudication and heart failure). Outcomes were assessed categorically as high-risk defined as a predicted probability of CVD >10%, and secondarily as a continuous measure of absolute risk (%). Modified Poisson and linear regression models adjusted for age, insurance, education, and income.Results:Among 4,310 nulliparous individuals, the median age was 27 years (IQR: 23-31), and the median ADI was 43 (IQR: 22-74). At 2-7 years postpartum (median: 4 years), the median 30-year risk of hard CVD was 2.3% (IQR: 1.5-3.5), and total CVD was 5.5% (IQR: 3.7-7.9). Individuals living in neighborhoods in the highest tertile of socioeconomic disadvantage were more likely to have a high 30-year predicted risk of hard CVD (≥10%) compared with those in the lowest tertile (aRR: 2.25; 95% CI: 1.23, 4.11), with similar results for high 30-year predicted risk of total CVD (aRR: 1.36; 95% CI: 1.09, 1.69). Living in the highest ADI tertile was associated with a higher absolute risk of 30-year hard (adj. ß: 0.41; 95% CI: 0.19, 0.63) and total CVD (adj. ß: 0.76; 95% CI: 0.38, 1.14) when analyzed as a continuous outcome.Conclusions:Neighborhood socioeconomic disadvantage in early pregnancy is associated with higher predicted risk of 30-year CVD 2-7 years after delivery.

Circulation, Volume 148, Issue Suppl_1, Page A18592-A18592, November 6, 2023. Introduction:Hypertensive disorders of pregnancy (HDP) are associated with an increased risk of maternal cardiovascular (CV) disease. Lactation is associated with favorable metabolic and CV profiles, but its impact on blood pressure (BP) recovery following a HDP is less clear.Hypothesis:Longer lactation duration is associated with lower systolic and diastolic BP throughout the first year postpartum (PP).Methods:We utilized data from a randomized clinical trial of overweight and obese individuals with a HDP diagnosis and no pre-pregnancy hypertension. BP was assessed in triplicate along with self-reported lactation status at enrollment (6 weeks to 6 months PP) and follow up (8-12 months PP). Hypertension was defined as ≥130/80 mmHg or the use of anti-hypertensive medications. PP BPs were also obtained daily using home BP monitoring for the first six weeks, then one week per month for the remainder of the first year PP. We compared demographic and cardiometabolic outcomes by lactation status at both study visits using two-sample t-tests and chi-squared tests. We utilized multivariable logistic regression models to assess the relationship of lactation with hypertension and repeated BP measurements were fit to mixed-effects linear regression models by lactation status to assess BP recovery.Results:Data from 129 individuals included 14,177 home BPs. Overall, 81% of participants initiated lactation and mean lactation duration was 5.8 ± 4.0 months PP. At follow up (10.9 ± 2.1 months PP), both systolic (p=0.004) and diastolic (p=0.008) BP were lower in individuals who lactated compared to those who did not. Each month of lactation was associated with a 12% (aOR 0.88; 95% CI 0.78-0.98) decreased odds of hypertension at one year PP with adjustment for age, race, education, BMI. Lactating individuals had a healthier BP recovery profile (p

Circulation, Volume 148, Issue Suppl_1, Page A18355-A18355, November 6, 2023. Introduction:Hypertensive disorders of pregnancy (HDP) are associated with a significantly increased risk of hypertension (HTN) in the years following delivery. Despite this, postpartum follow-up rates are low and evaluation for HTN in the first year postpartum is not well described in clinical practice. Our objective is to describe patterns of ambulatory BP measurement in the year following delivery.Methods:We identified all patients in a large health system with a delivery from 2018-2020. We describe prevalence of ambulatory blood pressure (BP) measurements according to HTN subtype: preeclampsia, gestational HTN (GHTN), or chronic HTN (CHTN), as assessed by ICD-10 codes. Logistic regression was used to examine relationship between patient factors and BP measurement.Results:We identified 25,843 patients of whom 87% had at least 1 BP check after delivery. Patients with preeclampsia and CHTN were more likely to have an outpatient BP measurement compared to normotensive patients in all time periods (Table). Patients with GHTN only had higher rates of BP measurement in the early postpartum period.Among patients with any hypertensive disorder, factors associated with BP measurement within 12 weeks included age >30 years (odds ratio (OR) 1.31, 95% confidence interval (CI) 1.12-1.55) and cesarean delivery (OR 1.3, 95% CI 1.1-1.52). In contrast, patients who were non-Hispanic Black (OR 0.69, 95% CI 0.56-0.84), current smokers (OR 0.55, 95% CI 0.41-0.76), or had public insurance (OR 0.31, 95% CI 0.26-0.37) were less likely to have a BP measurement within 12 weeks.Conclusions:Most postpartum individuals have at least one blood pressure measurement within 12 weeks of delivery, though ongoing BP evaluation is less common after 12 weeks. Age and racial disparities in BP measurement are prevalent. Future work will characterize and evaluate blood pressure trends and treatment in this cohort.

Circulation, Volume 148, Issue Suppl_1, Page A17966-A17966, November 6, 2023. Background:Hypertensive disorders of pregnancy (HDP) are common among women and increase risk for cardiovascular disease later in life. Postpartum interventions can motivate healthy lifestyle changes but are not universally effective. Patient demographics insufficiently predict intervention response. Our goal is to use cluster analysis to determine how behavioral phenotypes are associated with response to a digital health intervention targeting postpartum women with HDP.Methods:We analyzed 122 participants in the STEP-UP Mom study, a randomized clinical trial comparing wearable step tracker and team-based gamification (intervention) to wearable step tracker alone (control) over 12 weeks. Behavioral characteristics were collected at baseline using validated surveys, to which we applied the k-means method to identify two distinct patient clusters. Linear mixed-effects models were used to estimate mean step count difference between arms from baseline across 12-week follow-up in each cluster.Results:Among the 122 participants, the median age was 33 years and 54% identified as Black. Participant characteristics in each cluster are shown in the Table. Participants in Cluster 1 had higher baseline steps, lower exercise self-efficacy and greater psychosocial distress. There was no significant difference in change in step count in the intervention arm compared to the control arm (-289 steps, 95% CI -1294, 717; p=0.57). Participants in cluster 2 had lower baseline steps, higher exercise self-efficacy, and less psychosocial distress. In cluster 2, participants in the intervention arm walked 1,309 more steps per day on average compared to the control arm (95% CI 475, 2144; p= 0.003).Conclusion:Participants had varied response to a digital health intervention based on behavioral phenotype. This finding may help identify individuals who may benefit from a higher touch or tailored intervention in future studies to increase step count in the postpartum period.

Circulation, Volume 148, Issue Suppl_1, Page A15371-A15371, November 6, 2023. Introduction:Preeclampsia (PE), a leading cause of maternal mortality, is linked to persistent pathological changes in the heart, predisposing the mother to increased risk of chronic cardiovascular (CV) disease later in life. PE is characterized by increased S-nitrosylated (SNO) proteins and nitroso-redox imbalance. We recently showed that mice lacking S-nitrosoglutathione reductase (GSNOR-/-mice), a denitrosylase that regulates protein S-nitrosylation, exhibit the clinical features of PE including maternal hypertension, blunted increase in cardiac output, abnormal remodeling of left ventricular (LV) cardiac structure, dysregulation in nitrosylation and nitroso-redox imbalance.Hypothesis:The nitroso-redox imbalance seen during pregnancy in GSNOR-/-mice persists in postpartum (PP), leading to increased maternal susceptibility to CV injury.Methods:Pregnant control (WT [C57Bl/6J]) and GSNOR-/-mice (N=5) were examined at baseline, late-stage pregnancy (17.5 dpc) and 6 weeks PP. LV structure, cardiac output and stroke volume were determined using echocardiography (Vevo 2100). Cardiomyocytes (CM) were isolated at 6 weeks PP and ROS and peroxynitrite levels determined using fluorescent dyes.Results:In WT mice, all normal maternal CV adaptions to pregnancy, reverted to pre-pregnant levels 6 weeks PP. In contrast, GSNOR-/-mice exhibited increased cardiac output (+21% vs. -19% in WT), stroke volume (+21% vs. -41% in WT), and LV chamber dimension (+13% vs. -4% in WT) at 6 weeks PP, indicating high cardiac output LV cardiomyopathy. CM isolated from GSNOR-/-hearts showed ~5-fold more ROS generation (9.9×10-4±9×10-5vs. 2.1×10-4±1.5 x10-4ΔF/Fmax.min-1) and elevated peroxynitrite levels (0.318±0.011 vs. 0.243±0.012 ΔF/F0) compared to WT at 6 weeks PP, suggesting the presence of nitroso-redox imbalance. All changes P