Prevention and Screening for Cardiometabolic Disease Following Hypertensive Disorders in Pregnancy in Low-Resource Settings: A Systematic Review and Delphi Study

Salisu Mohammed Ishaku; Kwame Adu-Bonsaffoh; Natasha Housseine; Roberta Lamptey; Arie Franx; Diederick Grobbee; Charlotte E. Warren; Joyce L. Browne

doi:10.5334/gh.1195

Prevention and Screening for Cardiometabolic Disease Following Hypertensive Disorders in Pregnancy in Low-Resource Settings: A Systematic Review and Delphi Study

Volume 18 (2023): Issue 1

By: Salisu Mohammed Ishaku , Kwame Adu-Bonsaffoh , Natasha Housseine , Roberta Lamptey , Arie Franx , Diederick Grobbee , Charlotte E. Warren and Joyce L. Browne

Open Access

|Apr 2023

Figures & Tables

Table 1

Results of systematic review displayed by authorship, year of publication, article titles and recommendations for prevention and screening of cardiometabolic and chronic kidney diseases in women with prior hypertensive disorders in pregnancy (HDP, preeclampsia, gestational hypertension and chronic hypertension in pregnancy).

PREVENTION AND SCREENING OF CARDIOVASCULAR DISEASES AND METABOLIC SYNDROME FOLLOWING HYPERTENSIVE DISORDERS IN PREGNANCY
AUTHORS	YEAR	COUNTRY	TITLE	RECOMMENDATIONS
Deborah B. Ehrenthal, Janet M. Catov	2013	United States	Importance of engaging obstetrician/gynecologists in cardiovascular disease prevention	Obstetricians and gynecologists should routinely counsel women on their risk for cardiometabolic disorders, as they have the best opportunities for doing so.
Emely J. Jones, Teri L. Hernadez, Joyce K. Edmonds, Erin P. Ferranti	2019	United States	Continued disparities in postpartum follow-up and screening among women with gestational diabetes and hypertensive disorders of pregnancy: A systematic review	Obstetricians and gynecologists should routinely counsel women on their risk for cardiometabolic disorders, as they have the best opportunities for doing so.
Anouk Bokslag, Wietske Hermes, Christianne J. M. de Groot, Pim W. Teunissen	2016	Netherlands	Reduction of cardiovascular risk after preeclampsia: The role of framing and perceived probability in modifying behavior	Counseling women on behavior modification should express the risk of cardiometabolic disorders as probability scores, expressed as chance of developing the disease condition.
Fitriana Murriya Ekawati, Sharon Licqurish, Jane Gunn, Shaun Brennecke, Phyllis Lau	2021	Indonesia	Hypertensive disorders of pregnancy (HDP) management pathways: Results of a Delphi survey to contextualize international recommendations for Indonesian primary care settings	Counseling on contraception should be done. Annual monitoring should be done.
Tessa E. R. Gillon, Anouk Pels, Peter von Dadelszen, Karen MacDonell, Laura A. Magee	2014	Multinational	Hypertensive disorders in pregnancy: A systematic review of international clinical practice guidelines	Postpartum lifestyle counseling for BMI should be done, especially in obese women.
T. Katrien J. Groenhof, Bas B. van Rijn, Arie Franx, Jeanine E. Roeters van Lennep, Michiel L. Bots, A. Titia Lely	2017	Multicountry	Preventing cardiovascular disease after hypertensive disorders of pregnancy: Searching for the how and when	It is not possible to identify a time point to commence screening for cardiovascular risk factors in women after an HDP. Women with HDP should be screened in a stepwise fashion (taking into account classical risk factors, HDP phenotype, genetics, etc.) starting at a young age. The first appropriate approach for the management of cardiovascular risks should be lifestyle modification.
T. Katrien J. Groenhof, Gerbrand A. Zoet, Arie Franx, Ron T. Gansevoort, Michiel L. Bots, Henk Groen, A. Titia Lely	2019	Netherlands	Trajectory of cardiovascular risk factors after hypertensive disorders of pregnancy: An argument for follow-up	Cardiovascular screening of women with a history of HDP should commence within the fourth decades of life.
Alisse Hauspurg, Malamo E. Countouris, Janet M. Catov	2019	United States	Hypertensive disorders of pregnancy and future maternal health: How can the evidence guide postpartum management?	Where feasible, blood pressure (BP) within the first year postpartum should be monitored, preferably by ambulatory BP monitoring (ABPM) or home BP monitoring, to improve hypertension detection rate. Health care providers should carry out postpartum cardiovascular disease (CVD) risk counseling and screening, as women are more motivated during this period. All maternity centers should formulate dedicated guidelines for women with HDP on their continuity of care from obstetricians/midwives, primary care physicians or specialists, as appropriate. Postpartum care counseling should be delivered within a trauma-informed model, as women with post-traumatic experience are less likely to return to health facilities for regular monitoring. Where feasible, women with HDP should be reviewed within a multidisciplinary clinic involving obstetricians/midwives, primary care physicians and cardiologists to reduce inequities in health. Where practicable, a dedicated postpartum clinic for HDP should be established to enhance and facilitate transition of care and to provide a window of opportunity to focus on improving cardiometabolic health, primary prevention of CVD and counseling on risk factor modification. The inclusion and utilization of best practice alerts in electronic medical records should be adopted to facilitate risk identification and improve follow-up. In women with HDP, regular BP and cholesterol screening should be more frequent and should start as soon as one year postpartum. Women with a history of HDP should be counseled to follow diets, such as the DASH diet, that are low in salt and animal fat and include a majority of fruits and vegetables and more plant-based protein. Women with HDP should be advised to do moderate exercise for at least 30 minutes a day, five times per week. Women who smoke cigarettes should be counseled on smoking cessation.
American Heart Association	2011	United States	Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: A guideline from the American Heart Association	Women with a history of hypertensive disorders of pregnancy should have careful screening, monitoring, and control of other CVD risk factors, such as hypertension, dyslipidemia and diabetes.
Maria Carolina Gongora, Garima Sharma, Eugene Yang	2018	United States	Hypertension during pregnancy and after delivery: Management, cardiovascular outcomes and future directions	A comprehensive pregnancy history tool for CVD risk assessment should be developed to enable elucidation of nontraditional CVD risk factors.
Canadian Hypertensive Disorders of Pregnancy Working Group/Society of Obstetricians and Gynecologists of Canada	2014	Canada	Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: Executive summary	Women who are overweight should be encouraged to attain a healthy body mass index (BMI) to decrease risk in future pregnancy (II-2A) and for long-term health. Women with preexisting hypertension or persistent postpartum hypertension should undergo the following investigations (if not done previously) at least six weeks postpartum: urinalysis; serum sodium, potassium and creatinine; fasting glucose; fasting lipid profile; and standard 12-lead electrocardiography. Women who are normotensive but have had a hypertensive disorder of pregnancy may benefit from assessment of traditional cardiovascular risk markers. All women who have had a hypertensive disorder of pregnancy should pursue a healthy diet and lifestyle.
Susanne H. E. Luitjes	2013	Netherlands	Implementation of Dutch guidelines on hypertensive disorders of pregnancy	Antenatal, intrapartum and postpartum care for patients with chronic hypertension should be provided by gynecologists.
Roopa Malik, Viral Kumar	2017	India	Hypertension in pregnancy	Lifestyle modification (maintenance of a healthy weight, increased physical activity and smoking cessation) are recommended. In women with history of recurrent and early onset preeclampsia, yearly BP, fasting blood glucose and BMI should be done.
J. Moodley, P. Soma-Pillay, E. Buchmann, R. C. Pattinson	2019	South Africa	South African 2019 national guidelines for hypertensive disorders in pregnancy	Depending on where the woman lives, a follow-up at a hospital or community health center should take place after one week. A three-monthly follow-up is recommended. Psychological health counseling and support should be provided.
Elizabeth Phipps, Devika Prasanna, Wunnie Brima, Belinda Jim	2016	United States	Preeclampsia: Updates in pathogenesis, definitions, and guidelines	A cardiovascular profile, including yearly assessment of BP, lipids, fasting blood glucose, and BMI, in women with a history of preterm preeclampsia or recurrent preeclampsia should be done.
Gitte Bro Schmidt, Martin Christensen, Ulla Breth Knudsen	2017	Denmark	Preeclampsia and later cardiovascular disease—What do national guidelines recommend?	Inform about risk of increase in BP and risk of CVD later in life Healthy diet, exercise, smoking cessation and healthy BMI Postpartum CVD risk screening Annual BP assessment and blood tests/other CVD risk factors Later life follow-up When to start screening: 3–5 months after index pregnancy; 10 years after PE; around the age of 50 Three months after delivery, screening for hypertensive disease Long-term monitoring of cardiovascular and metabolic risk factors recommended to patients after severe preeclampsia
Malia S. Q. Murphy, Graeme N. Smith	2016	Canada	Pre-eclampsia and cardiovascular disease risk assessment in women	The development of structured postpartum cardiovascular screening programs for women after HDP is essential. The timing and nature of postpartum intervention plays a key role in women’s receptivity to lifestyle change. Women are generally highly motivated to lower their CVD risk if interventions are available and accessible. Professional counseling and involvement are key to success. A combination of educational, nutritional and physical activity resources to target an individual’s specific needs is needed. Promotion of a healthy lifestyle in conjunction with close monitoring and treatment of individual CVD risk factors is likely to be the most promising approach to CVD prevention in young at-risk women.
Ellen W. Seely, Ann C. Celi, Jaimie Chausmer, Cornelia Graves, Sarah Kilpatrick, Jacinda M. Nicklas, Mary L. Rosser, Kathryn M. Rexrode, Jennifer J. Stuart, Eleni Tsigas, Jennifer Voelker, Carolyn Zelop, Janet W. Rich-Edwards	2020	United States	Cardiovascular health after preeclampsia: Patient and provider perspective	Increased awareness and action to prevent CVD after preeclampsia A clinician checklist to ensure communication of CVD risks (patients’ perspective) Enhanced training for clinicians on the link between preeclampsia and CVD (patients’ perspective) A postdelivery appointment with a clinician knowledgeable about the link between preeclampsia and CVD risk (patients’ perspective) Clinical programs primarily to serve patients in the first postpartum year, bridging obstetrical and primary care (patients’ perspective) CVD risk modification with periodic BP, weight, lipids and diabetes screening (patients’ perspective) Integrated efforts of patients, caregivers, researchers and national organizations are needed to improve CVD prevention after preeclampsia. Risk modification programs could start between six weeks and six months postpartum and could be delivered online, via a mobile device or peer-to-peer support in a safe community of shared experience (patients’ perspectives). The clinical postpartum program could start within the first year postpartum or years after. Follow-up should be limited to only women with HDP OR include women with other obstetrics indicators, such as preterm delivery, intrauterine growth restriction and gestational diabetes. Women should be educated and empowered to stop smoking, adopt a heart healthy diet and engage in physical activity to lower BP, weight, glucose and cholesterol.
National Institute for Health and Care Excellence	2019	United Kingdom	Hypertension in pregnancy: Diagnosis and management	Women who had HDP should be advised that this is associated with increased risk of hypertension and cardiovascular disease later in life. Women can reduce their risk of cardiovascular disease and hypertension by avoiding smoking and maintaining a healthy lifestyle and healthy weight.
Laura Benschop, Johannes J Duvekot, Jeanine E. Roeters van Lennep	2019	Netherlands	Future risk of cardiovascular disease risk factors and events in women after a hypertensive disorder of pregnancy	All women with HDP should be informed of their increased risk of metabolic syndrome and cardiovascular diseases in later life. Women with HDP (especially the overweight—BMI ≥25kg/m²) should be encouraged to adopt a healthy diet (fruits and vegetables) and healthy lifestyle (physical activity, no smoking, moderate alcohol, etc.). Screening for cardiometabolic risk factors should commence during the six- to eight-week postpartum visit (minus lipids profile) and annually thereafter (to include lipids profile).
Lauren Rockliffe, Sarah Peters, Alexander E. P. Heazell, Debbie M. Smitha	2021	United Kingdom	Understanding pregnancy as a teachable moment for behavior change: A comparison of the COM-B and teachable moments models	Counseling and health education information should be provided during pregnancy, as pregnancy provides a better teachable moment for the adoption of healthy living.
D. M. Folk	2018	United States	Hypertensive disorders of Pregnancy: Overview and current recommendations	If counseling was not provided during pregnancy, the next best opportunities should be either in the immediate postpartum period before discharge or during the two-week postpartum review. Women who had preeclampsia should be counseled postpartum about the risks of cardiovascular diseases and be referred to a primary care provider or cardiologist for continued follow-up care.
S. A. Lowe, L. Bowyer, K. Lust, L. P. McMahon, M. Morton, R. A. North, M. Paech, J. M. Said	2014	Australia and New Zealand	Society of Obstetric Medicine of Australia and New Zealand (SOMANZ): Guideline for the management of hypertensive disorders of pregnancy 2014	Women who have had preeclampsia should be counseled that they will benefit from avoiding smoking, maintaining a healthy weight, exercising regularly and eating a healthy diet. All women with previous preeclampsia or hypertension in pregnancy should have an annual BP check and regular (five yearly or more frequent if indicated) assessment of other cardiovascular risk factors, including serum lipids and blood glucose.
PREVENTION AND SCREENING OF CHRONIC KIDNEY DISEASES
German Association of Obstetrics and Gynecology	2010	Germany	Diagnostik und Therapie hypertensiver Schwangerschaftserkrankungen: Arbeitsgemeinschaft Schwangerschaftshochdruck/Gestose AWMF	Three months after delivery, screening for renal disease should be done. Long-term monitoring of renal risk factors should be recommended to patients after severe preeclampsia.
National Institute for Health and Care Excellence	2019	United Kingdom	Hypertension in pregnancy: Diagnosis and management	Women with HDP should have their urine protein estimated six to eight weeks postpartum. If there is no proteinuria or hypertension during this review, no further follow-up is necessary.
Canadian Hypertensive Disorders of Pregnancy Working Group/Society of Obstetricians and Gynecologists of Canada	2014	Canada	Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: Executive summary	Women with a history of severe preeclampsia (particularly those who presented or delivered before 34 weeks’ gestation) should be screened for preexisting hypertension and underlying renal disease. Referral for internal medicine or nephrology consultation (by telephone if necessary) should be considered for women with (i) postpartum hypertension that is difficult to control or (ii) women who had preeclampsia and have at three to six months postpartum either ongoing proteinuria, decreased estimated glomerular filtration rate (eGFR) (<60 mL/min) or another indication of renal disease, such as abnormal urinary sediment.

Table 2

Recommended guiding practices for prevention and screening of cardiometabolic and kidney diseases in women with prior hypertensive disorders in pregnancy (HDP), for use in low- and middle-income countries (LMICs).

GUIDELINE NO.	IDENTIFYING WOMEN WITH HDP
1.	As recommended by the ISSHP, HDP should be classified as chronic hypertension in pregnancy, gestational hypertension and preeclampsia.
2.	Chronic hypertension in pregnancy should be diagnosed as any hypertension with onset before the index pregnancy or diagnosed within the first 20 weeks of the index pregnancy.
3.	Gestational hypertension should be defined as hypertension arising de novo after 20 weeks’ gestation in the absence of proteinuria and without biochemical or hematologic abnormalities.
4.	Preeclampsia should be diagnosed as de novo hypertension after 20 weeks’ gestation accompanied by proteinuria and/or evidence of maternal acute kidney injury, liver dysfunction, neurological features, hemolysis or thrombocytopenia or fetal growth restriction.
	Timing of First Counseling/Health Education
5.	Counseling on cardiometabolic risk following HDP should start early in pregnancy with the diagnosis of the condition.
6.	If counseling was not provided during the pregnancy, the next best opportunities should be either in the immediate postpartum period before discharge or during the two-week postpartum review.
	Structure and Setting of Care
7.	Counseling should be performed at facilities that women can access and by any available trained health care provider, regardless of their specialty.
8.	Where feasible, women with HDP should be reviewed within a multidisciplinary clinic involving obstetricians/midwives, primary care physicians, cardiologists and mental health experts.
9.	Obstetricians, midwives and maternity care providers should routinely counsel women with HDP on their risk for cardiometabolic and kidney disorders.
10.	Where practicable, a dedicated postpartum clinic for HDP be established to facilitate transition of care and to provide a window of opportunity to focus on improving cardiometabolic health, primary prevention of cardiovascular disease (CVD) and counseling on risk factor modification.
11.	The inclusion and utilization of best practice alerts in electronic medical records should be adopted to facilitate risk identification and improve follow-up.
12.	All maternity centers should formulate a dedicated guideline for women with HDP for their continuity of care from obstetricians/midwives, primary care physicians or specialists, as appropriate.
13.	All maternity centers should develop a comprehensive pregnancy history tool for CVD risk assessment to enable elucidation of nontraditional CVD risk factors (for example, gestational diabetic, intrauterine growth restriction and preterm delivery).
14.	Women with other nontraditional risk factors for cardiometabolic diseases, such as gestational diabetes, intrauterine growth restriction and preterm delivery, should also be counseled and monitored postpartum.
15.	Where feasible, the antenatal care card/folder/record should be modified to include a section on documentation of postpartum risk assessment and monitoring of long-term risks of chronic medical conditions associated HDP and other pregnancy complications.
16.	All health care providers of maternity services should be trained on the links between HDP and cardiometabolic and chronic kidney disorders.
17.	A health care provider checklist should be provided as a working tool to ensure detailed and balanced communication of cardiometabolic disease risks to patients with HDP.
	Counseling Information Needs for women Identified with HDP
18.	All women with HDP should be informed of their increased risk of cardiometabolic and chronic kidney diseases in later life.
19.	Counseling women on behavior modification should express the risk of cardiometabolic disorders as probability scores, expressed as chances (%) of developing the disease condition.
20.	Women with HDP (especially women who are overweight—BMI ≥25kg/m2) should be informed that postpartum lifestyles modification, as the first approach, substantially reduces the risk of cardiometabolic diseases in later life.
21.	Lifestyle modification should include adopting a healthy diet (all or any combination of consumption of fruits, vegetables, plant protein and oily fish and reduction or combination of any of diets low in salt and animal fats) and adoption of a healthy lifestyle (physical activity, no smoking, no or moderate alcohol, maintaining a lean BMI less than 25kg/m²).
22.	Aerobic exercise, such as brisk walking, for at least 30 minutes per day at least five days per week should be encouraged. Women should be informed that if they are able to exercise beyond the recommended level (30 minutes per day at least five days per week), the cardiometabolic benefits are even greater.
	Screening for Cardiometabolic and Kidney Disease Risk Markers
23.	Screening for cardiometabolic risk factors should commence at six to eight weeks postpartum (measurement of BP, BMI and fasting blood glucose).
24.	Lipid profiling (total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides) should not be undertaken during the six-week postpartum screening.
25.	If feasible, the first screening schedule at six to eight weeks postpartum should be integrated with the six- to eight-week postpartum review by obstetricians/midwives or other maternity care providers, as appropriate, for continuity of care and to enhance compliance.
26.	If cardiometabolic markers are normal during the six- to eight-week postpartum screening, women should be referred to their primary care providers for continuation of follow-up and ongoing screening.
27.	If cardiometabolic markers are abnormal during the six- to eight-week postpartum screening, women should be referred to cardiologists or general physicians for continuation of follow-up and ongoing screening.
28.	Further cardiometabolic risk screening should be undertaken at six months postpartum and annually thereafter. This should include lipid profiling (measurement of BP, BMI, fasting blood glucose, total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides).
29.	Women with HDP with persistent proteinuria and/or hypertension at six to eight weeks postpartum should be reassessed at three to six months postpartum. Women with ongoing proteinuria, decreased estimated glomerular filtration rate (eGFR) (<60 mL/min) or another indication of renal disease, such as abnormal urinary sediment, should be referred for a nephrology review.
	Indicators of Abnormal Cardiometabolic Markers
30.	Both women and their caregivers should be informed that their BMI should be maintained at ≤25 kg/m².
31.	Both the women and their caregivers should be informed that lipid profiles should be maintained at <1.7 mmol/l for triglycerides and >1.29 mmol/l for HDL cholesterol.
32.	Both the women and their caregivers should be informed that BP should be <120 mm Hg for systolic BP and <80 mm Hg for diastolic BP.
33.	Both the women and their caregivers should be informed that their fasting blood glucose should be maintained at < 5.6 mmol/l or <100 mg/dl.

Articles in this issue

DOI: https://doi.org/10.5334/gh.1195 | Journal eISSN: 2211-8179

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Language: English

Submitted on: Sep 12, 2022

Accepted on: Mar 27, 2023

Published on: Apr 25, 2023

Published by: Ubiquity Press

In partnership with: Paradigm Publishing Services

Publication frequency: 1 issue per year

Keywords:

Hypertensive disorders in pregnancy,

risks of future cardiometabolic diseases,

prevention and screening strategies

© 2023 Salisu Mohammed Ishaku, Kwame Adu-Bonsaffoh, Natasha Housseine, Roberta Lamptey, Arie Franx, Diederick Grobbee, Charlotte E. Warren, Joyce L. Browne, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 18 (2023): Issue 1