Risultati per: Linee guida sull’emorragia postpartum

Circulation, Volume 150, Issue Suppl_1, Page A4147618-A4147618, November 12, 2024. Introduction:People of color and non-English speakers are underrepresented in research and disproportionately affected by health-related social needs (HRSNs). Research engagement can be particularly challenging after pregnancy as postpartum care attendance is low. We describe our experience with remote recruitment modalities in a such a population.Methods:The study population included all patients affected by hypertension during a pregnancy who delivered at a large safety-net hospital 1/2022-6/2023. These patients also engaged in 6 weeks of remote blood pressure monitoring postpartum. Patients were contacted between 6 weeks and 12 months post-delivery to complete an online survey regarding HRSNs and provide consent to link survey data to clinical data. The recruitment protocol included initial outreach via the electronic medical record (EMR) patient portal, if available, or else a hard copy letter via mail, followed by a series of text messages then phone calls. All communication was conducted in the patient’s primary language (English, Spanish, or Haitian Creole).Results:We recruited 148 (9.4%) of 1571 patients contacted. Respondents were 51% Black, 39% Latina, 26% White. Table illustrates the comparable rate of recruitment across languages, dominance of EMR as mode of engagement and an illustration of the high rate of complex HRSN among our participants. The most effective recruitment method was EMR communication (57% of total recruitment) followed by text messages (28%). Our Haitian Creole-speaking respondents had the highest rates of HRSN – possibly representing the Haitian migrant crisis affecting Boston in this time period – as well as the highest rate of engaging via EMR messaging. Other domains of HRSN were high among all language groups including trouble affording medication (11-23%) and heating/electric access (21-34%).Conclusions:A diverse postpartum population with a high prevalence of HRSNs is hard to engage in research. Despite presumed digital barriers, EMR and secure text were effective and secure methods of online survey recruitment. Future studies seeking to understand the intersection of health outcomes and HRSNs should consider adding recruitment with EMR to common texting strategies.

Circulation, Volume 150, Issue Suppl_1, Page A4145437-A4145437, November 12, 2024. Background:Hypertensive disorders of pregnancy (HDP), including preeclampsia and gestational hypertension, are associated with increased risk of cardiovascular disease (CVD) later in life. This effect is strongly mediated by the subsequent development of chronic hypertension (HTN). Our objective is to identify clinical factors associated with incident HTN in a racially diverse cohort of postpartum patients using electronic health record (EHR) data.Methods:We identified patients with a delivery at Penn Medicine between 2012 and 2020 who did not have chronic HTN prior to delivery. The primary outcome was HTN between 6 and 24 months postpartum. HTN was identified based on ≥1 ICD code or ≥2 blood pressures (BP) ≥140/90. Univariable and multivariable logistic regression was used to model the association between patient factors assessed during pregnancy through the 6-week postpartum visit and incident HTN.Results:In the final cohort of 34,074 unique patients, mean age was 29.6 years, 42% identified as Black, and 38% had Medicaid insurance. A total of 1,078 patients (3.2%) developed incident HTN between 6 and 24 months postpartum. HTN was more common in patients with HDP compared to those without HDP (8.6% vs. 1.6%, p< 0.001). Factors independently associated with HTN are listed in the Table. After adjusting for patient demographics and clinical factors, older maternal age, Black race (vs. White race), preterm birth, obesity, diabetes, HDP, and 6-week postpartum systolic BP (SBP) were associated with HTN. HDP (OR 3.8, 95% CI 3.2, 4.5) and pre-pregnancy BMI ≥35 kg/m2 (OR 2.2, 95% CI 1.8, 2.7) were associated with the highest odds of incident HTN. Every 1 mmHg increase in postpartum SBP was associated with a 6% higher odds of incident HTN, after adjusting for HDP and other clinical factors.Conclusions:Patient factors that are routinely collected in the EHR, including HDP and BMI, are strongly associated with increased risk of developing incident HTN between 6-24 months postpartum in a racially diverse cohort. SBP at 6-weeks postpartum is an independent and underappreciated risk factor for HTN. Future work will develop and validate prediction models of incident postpartum HTN in this population at risk for CVD.

Circulation, Volume 150, Issue Suppl_1, Page A4141249-A4141249, November 12, 2024. Background:Hypertensive disorders of pregnancy (HDP) is a leading cause of pregnancy-related mortality in the United States and an important risk factor for postpartum cardiovascular disease (CVD). Previous animal data suggested that FSTL3 expression may be pathogenic in the development of cardiovascular dysfunction. The incidence of CVD during pregnancy has been increasing over time, which highlights the need to identify biomarkers that affect the development of the disease. We therefore hypothesized that peripartum FSTL3 levels would be associated with postpartum cardiovascular dysfunction and maternal morbidity.Methods:Pregnant patients age ≥ 18 years and singleton < 41 weeks with preeclampsia or superimposed preeclampsia who delivered at the University of Chicago between May 2017 and November 2020 were included in this observational cohort study. The primary outcome was cardiovascular dysfunction defined as postpartum hypertension, cardiomyopathy (confirmed with echocardiography and cardiology consult), and pulmonary edema (confirmed with chest radiography). The secondary outcome was severe maternal morbidity. Categorical data were assessed with chi-square or Fisher’s Exact test. The association between FSTL3 levels and postpartum CV dysfunction was assessed using multivariable logistic regression.Results:Our study included 408 patients, of which 212 were diagnosed with HDP. The median age was 28 years old (IQR 23, 33), the median BMI was 33.4 (IQR 28.6, 39.3), and the majority were African American (67.1%). Elevated FSTL3 levels were associated with postpartum CV dysfunction (OR 1.02 [95% CI: 1.01, 1.04]; p < 0.001). After multivariable adjustment for delivery gestational age, maternal age, BMI, nulliparous, HDP, smoking, and diabetes, the association between FSTL3 and CVD persisted (p = 0.02). Table 1 outlines the association between FSTL3 and maternal/neonatal outcomes.Conclusion:This study demonstrates that the biomarker FSLT3 predicts postpartum cardiovascular dysfunction and is associated with maternal morbidity. Our findings suggest that FSLT3 may facilitate the development of CVD and that therapeutic strategies targeting FSLT3 may affect the course of postpartum cardiovascular dysfunction.

Circulation, Volume 150, Issue Suppl_1, Page A4140494-A4140494, November 12, 2024. Background:Primary care after pregnancy is recommended, especially for individuals with recent adverse pregnancy outcomes (APOs, such as preeclampsia or gestational diabetes), who are at increased risk for future heart disease. Health-related social needs (HRSNs) are recognized barriers to care, yet their pregnancy-related prevalence and associations with care are unknown. We sought to (1) describe the pregnancy-related prevalence of HRSNs, and (2) assess associations between pregnancy-related HRSNs and subsequent linkage to primary care.Methods:We analyzed electronic health record data for individuals with prenatal care and delivery (2018-2021) at our urban safety-net hospital. HRSNs were assessed via a routine screener, and we summarized individual responses during pregnancy through 6 weeks post partum as: any positive, all negative, or never screened. Postpartum linkage to primary care was defined as a completed primary care visit after 6 weeks through 1 year post partum. We analyzed the prevalence of HRSNs and their associations with linkage to primary care, using adjusted log-linked binomial regression models. In stratified models we assessed for effect modification by APO history and other variables.Results:Of 4941 individuals in our sample, 53% identified as Black non-Hispanic and 21% as Hispanic, 68% were publicly insured, and 93% completed ≥1 HRSN screening. Nearly 1 in 4 screened positive for any HRSN, most often food insecurity (14%) or housing instability (12%), and 53% linked to primary care. Compared with those who screened negative for all HRSNs (n=3491), linkage to primary care was similar among those who screened positive for any HRSNs (n=1079; adjusted risk ratio, aRR 1.04, 95% confidence interval, CI: 0.98-1.10) and lower among those never screened (n=371; aRR 0.77, 95% CI: 0.68-0.86). We found no evidence of effect modification by APO history, race/ethnicity, insurance, language, or Covid-19 pandemic exposure.Conclusions:In this diverse postpartum sample, we identified a 24% prevalence of pregnancy-related HRSNs and 53% subsequent linkage to primary care. Linkage to primary care was not associated with HRSN screening result (positive versus negative) but was significantly negatively associated with being missed by HRSN screening. Further research is needed to better understand HRSN screening practices and who is missed by screening, and to identify modifiable barriers to postpartum primary care especially after APOs.

Circulation, Volume 150, Issue Suppl_1, Page A4145391-A4145391, November 12, 2024. INTRODUCTION:Pregnancy is marked by cardiovascular and hemodynamic changes to enable normal placental-fetal growth but may also predispose women to adverse outcomes including hypertensive disorders. Studies have assessed the plasma proteome of hypertension, but proteomic biomarkers of maternal blood pressure (BP) through pregnancy and postpartum remain unexplored.OBJECTIVES:Explore the 1sttrimester (TM) maternal plasma proteome in relation to systolic (S) and diastolic (D) BP in the 1stand 3rdthird TM, and 3 months postpartum.METHODS:We obtained baseline, 1stTM plasma samples from n=435 women from an antenatal multiple micronutrient vs iron-folic acid supplement trial in rural NW Bangladesh (West et al JAMA 2014). Phlebotomy occurred

Circulation, Volume 150, Issue Suppl_1, Page A4143849-A4143849, November 12, 2024. Background:Maternal mortality in the United States continues to rise, with hypertensive disorders of pregnancy (HDP) playing a significant role in adverse outcomes. Patients of color have worse outcomes compared to their White counterparts. Data in non-pregnant patients suggests community health workers (CHWs) can help mitigate disparities and improve HDP outcomes. Does exposure to a CHW improve patient education about HDP and satisfaction and are these findings different between Black and non-Black patients?Methods:This was a prospective survey study that enrolled patients delivering at the University of Chicago (UCM). Patients with HDP are automatically enrolled in a standardized postpartum hypertension education program (STAMPP-HTN) where they receive education and a blue tooth compatible blood pressure monitor. Patients who did not record their blood pressures were contacted by a CHW and surveyed about their experience. Results were compared between Black and Non-Black patients using a Wilcoxon Rank Sum, X2or Fisher’s Exact test, as appropriate.Results:There were 32 survey responses from 22 respondents and 15 patients with complete baseline data, 6 of whom were Black and 9 of whom were non-Black. There were no differences in age, insurance status, or pregnancy outcomes between groups. Additionally, of the 32 survey responses, there were no significant differences in experiences with a CHW between Black and non-Black patients. Table 1 outlines the impact of CHW on patient’s education and attitude towards HDP. Most patients found that CHW involvement increased the amount of time they checked their blood pressure (76%) with no difference between races (p=0.23). Overall, 84% patients (strongly agreed or agreed) that their CHW knows the important issues about their healthcare.Conclusion:The incorporation of a CHW program into a pre-existing postpartum hypertension program was overall well-received by patients with no racial disparity. The program increased the patient’s understanding of HDP and lead to a better follow up of their blood pressures values. Further work is needed to determine how this program impacts long-term patient’s outcomes.

Circulation, Volume 150, Issue Suppl_1, Page A4142487-A4142487, November 12, 2024. Introduction:The US maternal mortality rate is rising, with cardiovascular disease being the main cause of death. Acute myocardial infarction in particular (most commonly ST-elevation myocardial infarction (STEMI)) is associated with excess mortality. There have been no recent large, population-based studies estimating the current incidence of postpartum STEMI or identifying its risk factors.Research Question:Given the increasing risk of postpartum STEMI and the consequences of such a diagnosis we sought to identify recent incidence of postpartum STEMI and understand its predictors.Goal:The purpose of this study was to describe the incidence and risk factors of acute postpartum STEMI in the USA.Methods:This study was performed using MarketScan Commercial Claims and Encounters Data. Patient selection was from all deliveries resulting in a live birth between 2017 and 2020 with claims data available for 12 months prior and 6 months following delivery data. For all births, STEMI within 6 months was noted and the following risk factors were collected: age, hypertension (HTN), thrombophilia, anemia, diabetes mellitus (DM), and smoking. We then performed multivariate logistic regression models to estimate odds ratio (95% confidence interval) for STEMI adjusted for the aforementioned risk factors.Results:327,570 delivery cases were identified, of which 3330 (1%) had a STEMI in the time from hospital admission to 6 months postpartum. Most STEMIs occurred close to the time of delivery: 2823 (84.8%) cases within 24 hours of delivery and an additional 132 within 1 week, 80 within 2 weeks, and 52 within 4 weeks (cumulative totals of 89.4%, 91.8%, and 93.3% respectively). The following factors had a significant, independent, positive correlation with STEMI: age ≥40 (OR 1.6 [95% CI 1.4-1.9]), DM (OR 1.6 [95% CI 1.5-1.7]), HTN (OR 1.6 [95% CI 1.5-1.7]), and smoking (OR 1.5 [95% CI 1.3-1.8]). These are shown in Figure 1.Conclusion:Although rare, postpartum STEMI is associated with high morbidity and mortality and is occurring at an increasing rate. While maternal age is not modifiable, HTN, smoking and DM are, and more should be done to address these risk factors in those who are, or plan to become, pregnant.