Hypertension in pregnancy

Hypertension in pregnancy A risk for later disease

A new research project aims to educate women and health care professionals about the increased risk of cardiovascular disease and diabetes after hypertension in pregnancy

For over 20 years, the link between hypertensive disorders of pregnancy (HDP) and longterm health risks has been recognised in scientific literature. As well as being a major cause of short-term maternal and fetal morbidity and mortality, women who experienced HDP are at significantly increased cardiovascular disease (CVD) risk in the future compared to women with no HDP pregnancies. A further key element, adding to the magnitude of concern, is that the onset of these HDPassociated CVD risks and deaths occur prematurely, within 10 years of an affected pregnancy with the risk continuing lifelong.

Despite this, a recent study has shown that both women and healthcare providers lack knowledge about these increased risks. Addressing this knowledge gap is now the focus of new SPHERE-funded research which aims to translate the findings into practice through a targeted education program for women with a history of hypertensive disorders in pregnancy.

Long-term health risks associated with HDP

The term HDP includes preeclampsia, gestational hypertension and chronic hypertension. While most people are aware that high blood pressure during pregnancy is a concern for both the mother and unborn child, relatively few are aware of the long-term health risks to women post HDP, including a 2-3 times higher risk of developing cardiovascular disease as well as other chronic diseases such as Type 2 Diabetes (doubled risk) and chronic kidney disease (5-10 times higher).

Dr Heike Roth (UTS) conducted her PhD on knowledge gaps about health after hypertensive pregnancy, supervised by Professor Caroline Homer (Burnet Institute and UTS), foundation lead of SPHERE’s Maternal Newborn and Women’s Clinical Academic Group (MNW CAG), and A/Prof Amanda Henry (UNSW), current co-lead of MNW CAG. Dr Roth’s PhD and now postdoctoral work is partially supported by the MNW CAG, and showed that there is a considerable knowledge gap regarding health after HDP among both women and healthcare practitioners. Dr Roth, in collaboration with A/Prof Henry, is now working on closing this gap.

“Globally, cardiovascular disease (CVD) is one of the leading causes of death in women. This is also true for women living in Australia. Cardiovascular disease kills more women than any other disease which is why it’s so important to share knowledge with women about their increased risks and ways in which some of them may be mitigated,” explains Dr Roth.

“We have this window of opportunity where we know the women who are at increased risk and we know that some of these risks can be minimised with lifestyle adjustments or caught early by implementing preventive screening measures.

“Some of the lifestyle adjustments include healthy eating and exercise. Preventive measures also include yearly blood pressure monitoring and regular screening for metabolic disorders.”

The knowledge gap findings

Dr Roth’s initial doctoral research involved a series of surveys and interviews looking at the knowledge that both women and healthcare providers have about long-term health risks after HDP in pregnancy.

Of the 266 women surveyed, 174 had a history of HDP and 92 had history of no HDP.

In total, 492 healthcare providers were surveyed including 26 cardiologists, 188 obstetricians, 203 midwives and 75 general practitioners with additional study in gynaecology/ obstetrics.

“In both cohorts (women and healthcare providers) we found that most know there is an increased risk of HDP recurring in the next pregnancy and that future hypertension, outside of pregnancy, may develop. However, we found significant gaps in knowledge about the risk of heart disease, diabetes and renal disease after HDP.

“The poorest knowledge was regarding the risk of diabetes. A woman who had HDP has a higher risk of developing Type 2 diabetes even if she didn’t have gestational diabetes and yet there was very limited knowledge about this risk.”

“While cardiologists had excellent knowledge of the ongoing risks, there was much lower overall knowledge for all other healthcare providers surveyed. Only 34% were aware that risks start to manifest within 10 years of HDP. So, this was a concerning finding.”

Addressing the knowledge gap for women

Dr Roth’s findings of the significant knowledge gaps led to the next part of her research which involved interviewing women who had HDP as well as healthcare providers to explore their preferred educational content, format and access to health information after HDP. Healthcare providers were also asked about their needs regarding transmission of knowledge to post HDP women in their care.

Women were keen to have access to information as soon as possible after birth (preferably before six months postnatal) and wanted that information to be easily accessible online. This has led to the development of a website which forms part of Dr Roth’s post-doctorate research, supported by MNW CAG funding.

The website, which is being trialled for 24 months, will provide 100 participants with essential information about their risks and ways to address these, as well as resources and links to organisations such as the Heart Foundation.

“We’re currently recruiting women who had HDP through St George Hospital and are waiting for approval to recruit from Liverpool and Campbelltown Hospitals as well.

“The aim of this pilot is to see if the website content is sufficient and if the website is easy to navigate and understand.”

Prior to gaining access to the website, women receive a pre-access survey which assesses their general knowledge about risks.

To assist the transition from maternal care to primary care, participants are sent reminders at six months and nine months to make a follow-up health appointment with their GP and are given suggestions regarding the key topics to address at that appointment.

“We also send information about the study to their nominated GP, letting them know the woman is a participant in the study and providing the GP with a tick-box pamphlet about the suggested topics to be covered during the appointment and what the long-term follow up optimally would look like so the GP can put in place reminders within their own booking systems.”

After accessing the website for six and 12 months, women are prompted to complete further short surveys which will gauge whether their knowledge of risk has improved compared to their pre-access survey.

“At 12 months postpartum the final survey looks at how useful the reminder system was perceived to be and what lifestyle adjustments the women may have made as a result of taking part in the study,” Dr Roth explained.

Addressing the knowledge gap for health professionals

A further study, supported by NSW Health through A/Prof Henry’s EarlyMid Career Fellowship and conducted as part of Ms Jennifer Green’s PhD (supervised by Dr Roth and A/Prof Henry) will address the healthcare provider aspect where the feasibility of implementing post HDP structured education and recommended followup with healthcare providers will be tested. An ethical application is in progress and a steering committee consisting of GPs, obstetric specialists and midwives has been formed. The study is expected to launch mid-2023.

“While this is only in the very early stages, our ultimate aim is to better inform healthcare providers by sharing resources that will not only be useful for their own knowledge acquisition but also their knowledge transmission to women in their care. We also hope to improve the transition of care between maternity services and primary healthcare providers such as GPs.”

Overall, these past, ongoing and upcoming projects will contribute to the current body of knowledge in this area. The evidence can be used to guide the development of larger scale education programs for women and

healthcare providers on health after HDP which may enhance knowledge, preventive health management and more generally improve women’s health trajectories.

For more information, contact Heike.Roth@uts.edu.au

Publications

Roth H, LeMarquand G, Henry A, Homer CSE. Assessing knowledge gaps of women and healthcare providers concerning cardiovascular risk after hypertensive disorders of pregnancy - A ccoping review. Frontiers in Cardiovascular Medicine. 2019;6(178).

Roth H, Homer CSE, LeMarquand G, Roberts L, Hanley L, Brown M. Henry A. Assessing Australian women’s knowledge and knowledge preferences about longterm health after hypertensive disorders of pregnancy: a survey study. BMJ Open 2020;10(12): e042920 doi: 10.1136/bmjopen-2020-042920

Roth, H., Henry, A., Roberts, L., Hanley, L., & Homer, C. S. E. (2021). Exploring education preferences of Australian women regarding long-term health after hypertensive disorders of pregnancy: a qualitative perspective. BMC Women’s Health, 21(1), 384. https://doi.org/10.1186/s12905-021-01524-w

Roth H, Homer CSE, Arnott C, Roberts L, Brown M, Henry A. (2020). Assessing knowledge of healthcare providers concerning cardiovascular risk after hypertensive disorders of pregnancy: an Australian national survey. BMC Pregnancy and Childbirth, 20(1), 717.

Roth, H., Morcos, V., Roberts, L. M., Hanley, L., Homer, C. S. E., & Henry, A. (2022). Preferences of Australian healthcare providers regarding education on longterm health after hypertensive disorders of pregnancy: a qualitative study. BMJ Open, 12(5), e055674. https://doi.org/10.1136/bmjopen-2021-055674