Comprehensive blood pressure management to improve early postpartum blood pressure parameters: A randomized controlled trial.

INTRODUCTION

Adherence to blood pressure (BP) evaluation 7-10 days after pregnancy complicated by hypertension is poor. Current guidelines for postpartum BP control are more liberal than those for nonpregnant individuals. Our objective was to determine whether a comprehensive BP management program and tight BP control improve BP outcomes at 7-10 days postpartum compared with clinician-directed management and standard targets.

METHODS

Postpartum patients with chronic or gestational hypertension, preeclampsia/eclampsia, or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome were randomized simultaneously to two interventions (four arms total): (1a) comprehensive management with remote BP monitoring and algorithm-based treatment, (1b) clinician-directed management at the primary obstetric provider's discretion, and (2a) tight (<140/90 mmHg) versus (2b) standard (<150/100 mmHg) BP control. Outcomes were measured at 7-10 days postpartum; the primary outcome was in-office BP evaluation and secondary outcomes included BP ascertainment (remote or in-person), BP change from baseline, antihypertensive medication initiation, any BP ≥140/90 mmHg or ≥160/110 mmHg, and all-cause emergency department visits or hospital readmissions.

RESULTS

From May 9, 2023 to August 1, 2024, 334 of 660 eligible participants were randomized. There was no difference for the primary outcome of in-person BP visit attendance between the comprehensive and clinician-directed management interventions (62.5% [n = 105/168] vs. 52.4% [n = 87/166]; adjusted odds ratio [aOR], 1.50, 95% confidence interval [CI], 0.94-2.39). Comprehensive management increased any BP ascertainment (remote or in-person) compared with clinician management (91.7% [n = 154/168] vs. 57.2% [n = 95/166]; aOR, 9.23, 95% CI, 4.76-17.91). Among participants randomized to tight control, comprehensive management reduced systolic BP compared with clinician management (-1.8 ± 16.5 vs. 5.7 ± 16.4 mmHg; adjusted beta coefficient, -9.23; 95% CI, -14.46 to -4.00). For participants in comprehensive management, tight control increased odds of medication initiation compared with standard control (32.1% [n = 17/53] vs. 8.2% [n = 4/49]; aOR, 4.25, 95% CI, 1.17-15.48).

CONCLUSION

A comprehensive postpartum BP management program with coaching and remote monitoring did not improve in-person BP visit attendance at 7-10 days postpartum but did increase odds of patients reporting any BP to a clinician. Findings from the secondary outcomes suggest that a tight BP target combined with the comprehensive BP management program reduced systolic BP and increased the odds of initiating new antihypertensives by 10 days postpartum.