# paper.pdf ## Metadata - PDFFormatVersion=1.4 - Language=en-US - IsLinearized=true - IsAcroFormPresent=false - IsXFAPresent=false - IsCollectionPresent=false - IsSignaturesPresent=false - CreationDate=D:20240610133323-04'00' - Creator=Adobe InDesign 19.4 (Macintosh) - ModDate=D:20240610133327-04'00' - Producer=Adobe PDF Library 17.0 - Trapped=False - xmp:createdate=2024-06-10T13:33:23-04:00 - xmp:metadatadate=2024-06-10T13:33:27-04:00 - xmp:modifydate=2024-06-10T13:33:27-04:00 - xmp:creatortool=Adobe InDesign 19.4 (Macintosh) - xmpmm:instanceid=uuid:bf60f602-a4eb-3045-9c4d-af3bbb10a987 - xmpmm:originaldocumentid=xmp.did:e6f5e802-ad87-3b47-bcb8-5ebc112763e9 - xmpmm:documentid=xmp.id:844b4443-7812-43ac-9d6a-ffacf73d27ef - xmpmm:renditionclass=proof:pdf - xmpmm:derivedfrom=xmp.iid:82ae05f1-b9fd-48f3-9385-4a5cb6e1ba5exmp.did:60eb704f-0661-4819-a2bd-d7727f1950ecxmp.did:e6f5e802-ad87-3b47-bcb8-5ebc112763e9default - xmpmm:history=convertedfrom application/x-indesign to application/pdfAdobe InDesign 19.4 (Macintosh)/2024-06-10T13:33:23-04:00 - dc:format=application/pdf - pdf:producer=Adobe PDF Library 17.0 - pdf:trapped=False ## Contents ### Page 1 PREVENTION, REPRODUCTIVE HEALTH AND CARDIO-OBSTETRICSSECTIONS OF THE AMERICAN COLLEGE OF CARDIOLOGY REPRODUCTIVE HEALTH& CARDIO-OBSTETRICS MEMBER SECTION PREVENTION OF CARDIOVASCULAR DISEASE MEMBER SECTION MASSACHUSETTS CALIFORNIA TENNESSEE Postpartum HypertensionClinic Development Toolkit ### Page 2 CONTENTS I. How to start a postpartum hypertension clinic for individualswith hypertensive disorders of pregnancy 1. Conceptualizing a postpartum hypertension clinic 2. Identifying and engaging key stakeholders 3. Leveraging successful clinic examples to obtain funding a. Understanding the value of postpartum hypertension clinics b. Benefits to health care systems c. Funding mechanisms 4. Overview of administrative logistics/coding 5. Checklist II. Clinic models/framework 1. Clinical models/operations a. Clinic models and staffing b. Types of visits c. Timing of visits d. Follow-up visits e. Referrals 2. Clinic activities 3. Coding/Billing III. Obstetric considerations after hypertensivedisorders of pregnancy 1. Contraception 2. Pregnancy and delivery debriefing 3. Screening for depression 4. Risk of recurrence IV. Postpartum blood pressure management 1. Postpartum hypertension medication titration 2. Remote blood pressure monitoring programs V. Clinic example documents, dot phrases, and other materials 1. Clinic notes 2. Letters to referring providers VI. Patient education VII. Appendices and References 1. Acknowledgements ### Page 3 Part I How to start a postpartumhypertension clinic for individuals withhypertensive disorders of pregnancy 1. Conceptualizing a postpartum hypertension clinic ### Page 4 ### Page 5 patient-facing educational materials, includingbrochures, educational videos, and website materialsdescribing the relationship of hypertensive disordersof pregnancy to future cardiovascular disease as wellas to provide information introducing the postpartumprograms (see examples in Part 6: Patient education). In addition, the incorporation of remote bloodpressure monitoring programs can provideblood pressure data that guides blood pressuremanagement at a postpartum hypertension clinic.In the immediate post discharge period, remoteblood pressure monitoring can serve as a bridge to apostpartum visit when there is a high risk of persistent,uncontrolled hypertension. Postpartum remotemonitoring of blood pressure can identify patientswho remain hypertensive and have the highest needto be seen in a postpartum hypertension clinic. Therecent POP-HT trial showed better postpartum bloodpressure control among individuals enrolled in aremote blood pressure monitoring program. Creatinga postpartum remote blood pressure monitoringprogram requires the following key items: (1) patientsmust receive a validated blood pressure device() with an appropriate-sized cuff and instruction on how to accuratelyperform self-monitored blood pressure, (2) a way totransfer home blood pressures into the electronicmedical record via smart phone application, text,website, or through a patient portal, (3) a care modelfocused on managing postpartum hypertension, (4)education on severe hypertension and symptoms.See additional details in Part 4: Postpartum bloodpressure management. Example timeline for 1-year development of a postpartum hypertension clinic | Q1 | Q2 | Q3 | Q4 | | - | - | - | - | | Stakeholder meetings every other week | | Develop clinic protocols | | Schedule clinic dates | | Create/adapt/identify educational materials | | Train clinic staff | | Begin patient visits | | Collect/analyze data on clinic objectives | ### Page 6 Key stakeholders should be identified prior to clinicinception and may include the following (figure): PART I 2. Identifying and engaging key stakeholders Clinicians inpostpartumhypertension clinic: Ob-gyn,primary care,family medicine,cardiology,nephrology Other cliniciansproviding longitudinalcare: Primary care,family medicine,pediatricians, Ob-gyn,mental healthproviders Allied healthprofessionals: Nurses, pharmacists,doulas, social workers,nutritionists STAKEHOLDERS IN THEDEVELOPMENT OF POSTPARTUMHYPERTENSION CLINIC Administrationand leadership: Department andhealth system leaders,clinic administrators,directors of otherpostpartumclinics Community: Community members,community healthworkers, communityorganizations Patientsandfamilies ### Page 7 a. Understanding the value of postpartumhypertension clinics Postpartum hypertension clinics aimed at blood pressuremanagement, optimization of cardiovascular risk factors,and primary prevention of cardiovascular disease havethe potential to improve health at the individual levelby reducing maternal morbidity and mortality, provideimmense benefit to the community, and reduce long-term health care costs. Cardiovascular disease is the leading cause of deathfor women, yet cardiovascular disease mortality ratesamong young women remain alarmingly stagnant.1,2Pregnancy induced hypertensive disorders, preeclampsiaand gestational hypertension, provide a sex-specificwindow to susceptibility for cardiovascular disease witha strong association with later life cardiovascular diseasedemonstrated across diverse populations.3–6 Individualswith pregnancy-induced hypertension and other adversepregnancy outcomes have excess cardiometabolic riskand progress to overt cardiovascular disease at youngerages compared with individuals with uncomplicatedpregnancies. The American Heart Association and theAmerican College of Obstetricians and Gynecologists(ACOG) have identified hypertensive disorders ofpregnancy as a risk factor for cardiovascular disease witha magnitude of risk on par with smoking and diabetes.As such, they have recommended that individuals withhypertensive disorders of pregnancy have close follow-up with a cardiologist or primary care physician forscreening and management.7,8 The translation of theserecommendations into clinical practice has not occurredwithin most hospital systems, representing a missedopportunity to improve cardiovascular disease awareness,prevention, and reduce care inequities for women. While some clinicians are acutely aware of this risk,there are many barriers beyond clinicians’ knowledgebase which may impede patient education about theirfuture cardiovascular risk. Identifying the appropriatetiming and venue for counseling is challenging. Muchof this counseling occurs immediately after deliveryin the hospital, which is often a busy and emotionalperiod for birthing individuals. Amidst the delivery of anewborn with many physical changes, pain, and sleepdeprivation, it is not surprising that birthing individualsdo not retain all of the information that the care teamcommunicates to them at the time of delivery.9 Inaddition, the implementation of recommended testingand interventions for cardiovascular risk reduction areoften delayed or neglected. Fragmented postpartumcare contributes to the frequent absence of a cohesivetransition from the obstetrician to an internist or PART I 3. Leveraging successful clinic examples to obtain funding ### Page 8 cardiologist as is recommended by ACOG.10 Thus,all too often, birthing individuals are unaware ofthe association between hypertensive disorders ofpregnancy and future cardiovascular risk, highlightingthe need for a dedicated time and space to discuss thisrisk outside of the delivery hospitalization.11 In the early postpartum period, individuals withhypertensive disorders of pregnancy have increased riskof cardiovascular morbidity (heart failure, myocardialinfarction, stroke) and contribute to the rising ratesof maternal mortality in the United States. Individualswith hypertensive disorders of pregnancy also havehigher rates of health care utilization in the first yearpostpartum with more frequent emergency room visitsand hospitalizations than individuals with normal bloodpressure. Adverse pregnancy outcomes are oftenoverlooked during those interactions with the healthcaresystem and identify a missed opportunity to reducepostpartum morbidity and mortality. In addition to short term increases in morbidity andmortality related to pregnancy-induced hypertension,many birthing individuals have an increased risk fordeveloping sustained hypertension in the fourthtrimester. Prior studies have found that over 40% ofindividuals with a history of severe preeclampsia stillhad significant hypertension one year after delivery andthose who were on antihypertensive therapy did nothave optimal control.12 In a single center study, 60% ofoverweight and obese birthing individuals developedchronic hypertension by one year postpartum.13 Thereare also differences in postpartum blood pressure byrace, where Black individuals have been found to havehigher postpartum blood pressures.14 It is importantfor hypertension management and cardiovascular riskcounseling to be reinforced at the 6-week obstetricianvisit. However, historically up to 40% of postpartumindividuals do not attend a postpartum visit within 6weeks, affording an important opportunity to addressbarriers to postpartum follow-up and have additionalfollow-up mechanisms in postpartum hypertensionclinics. In addition, beyond the typical follow-up periodof 6 weeks postpartum, there is an ongoing needfor blood pressure monitoring and management forindividuals with pregnancy-induced hypertension. Pregnancy provides a critical window to identifyindividuals at high risk of developing future cardiovasculardisease and represents a time when individuals seekhealth care and are engaged with the health care system.Postpartum clinics for individuals with hypertensivedisorders of pregnancy help support parents caring fortheir newborns, keep birthing individuals engaged with PART I 3. Leveraging successful clinic examples to obtain funding ### Page 9 care, identify cardiovascular risk factors, and implementscreening and intervention strategies to improve long-term health.15 b. Benefits to health care systems In addition to improving care for postpartum individualswith hypertensive disorders of pregnancy, postpartumhypertension clinics and remote monitoring programshave financial advantages for health care systems. First,more patients are retained in the healthcare systemin the postpartum period. Not only are these patientsseen for visits in the postpartum hypertension clinic,but they are also more likely to develop relationshipsand then follow longitudinally with a subspecialist orprimary care provider15 for themselves as well as to bringfamily members into the system. Second, postpartumhypertension clinics have the potential to reduceemergency room visits and thus unnecessary postpartumhospital admissions, as has been seen in remote bloodpressure monitoring programs16. Though it is importantto note that in some cases, acute severe hypertensionin the postpartum period is a medical emergency thatwarrants admission for treatment and evaluation ofpostpartum preeclampsia. In tandem, postpartum remotemonitoring programs and postpartum hypertensionclinics can provide a safe, expert, and timely mechanismfor postpartum blood pressure management withouthealthcare over-utilization. Third, patients seen inpostpartum hypertension clinics can be billed at a highlevel that reflects the intensity and complexity of servicesprovided. Lastly, the cardiovascular disease preventionthat occurs as part of a postpartum hypertension clinicmay reduce long term health care costs associated withcardiovascular morbidity. c. Funding mechanisms Small local or hospital-based grants ($10,00-$50,000)can be helpful in launching a postpartum hypertensionclinic. These funds can be used to support the following: • pilot testing of remote blood pressure monitoringprograms, including developing infrastructure andcare models needed to support such programs • purchase of blood pressures cuffs (includingextra-large size) • clinic staff (nurses, coordinators, medical assistants,pharmacists, social workers) • patient transportation • medication and medication delivery • development of educational and advertising materials PART I 3. Leveraging successful clinic examples to obtain funding ### Page 10 Patients should generally be scheduled as a new patientvisit. It is important to incorporate synchronous andasynchronous telemedicine into the clinic model, asvirtual visits are often more convenient for new parentsand can help to reduce cancellation and no-showrates17. Virtual visits require patients to have a homeblood pressure cuff to provide blood pressure measuresfor management discussion during the clinic visit andtypically need to reside in the same state as the clinic.For multidisciplinary clinics (e.g., maternal fetal medicineand cardiology or nephrology), all patients can be seenby both clinicians. The visit can be billed as a singlesubspecialist or two separate subspecialist visits, codedto reflect the complexity and intensity of the visits. Eachclinician documents an individual note for the patientfollowing the visit (single encounter or two encounters)and a joint consult letter (if single encounter) can be sentto each patient’s obstetrician, primary care clinician, andall other key members of their care team. See additionaldetails in Part 2. Clinic models / framework. PART I 4. Overview of administrative logistics/coding 5. Checklist Postpartum Hypertension Clinic Development Checklist | ![Checkmark with solid fill]() | Checklist Items | | - | - | | Identify key clinicians, stakeholders, and administrative support staff | | Schedule regular meetings with stakeholders and administrators | | Develop clinic framework, protocols, workflow, schedule, and coding structure | | Develop blood pressure monitoring protocols and decide blood pressure goals across the 4th trimester in collaboration with key stakeholders | | Create clinic materials: dot phrases, note templates, letters, patient education documents | | Train clinic staff | | Promote clinic to referral base | | Incorporate remote blood pressure monitoring programs | | Monitor clinic volume and outcomes | ### Page 11 Part II Clinic models/framework 1. Clinical models/operations Clinic models Consider telemedicine andHBPM to improve access Clinic referral Automated All patients meeting criteria Opt-in or opt-out Visit scheduled prior to hospital discharge Combined obstetrics & specialty model Co-located clinic. Encounters can be shared or separate. Clinician-initiated High-risk patients referred from inpatientor outpatient OB, MFM, primary care, or sub-specialist EHR order set Primary care or subspecialty model Specific postpartum visit typecan help maintain timely access. Obstetrics or family medicine model Patient-initiated Scheduled in addition to postpartumvisit to focus on CV prevention All patients given info about clinic and cancall to schedule Printed info at discharge, website ### Page 12 PART II 1. Clinical models/operations a. Clinic models (Figure) Combined clinic model: Cardiology/Primary Care/Nephrology PLUS Obstetrics/Maternal Fetal Medicine(MFM) • Typically, a cardio-obstetrics clinic or dedicatedpostpartum hypertension clinic • Patient is scheduled for 40-minute slot and is seenby both (1) cardiology (or primary care or othersubspecialist) and (2) obstetrics/MFM, with 20 minutesfor each clinician. Can also consider shorter time slots,particularly if planning follow-up visits. • Each clinician can document a separate note underone encounter or under separate encounters forseparate coding • Can typically accommodate between 8 to 14 newpatients per half clinic day, depending on theschedule timing. • If under one encounter, a joint consult letter is sentto the referring clinician, primary care clinician, andobstetrician. If each subspecialist provider is undertheir own encounter (two separate encounters), twoletters are sent. Single specialty postpartum clinic model: Obstetrics/MFM • Patient is scheduled into a dedicated postpartumclinic located in the obstetrics clinic, for a 20 to 40minute visit. Can also consider shorter time slots,particularly if planning follow-up visits. • In some models, the patient is seen by both a nurse(history data collection) and clinician. Single specialty postpartum clinic model: Cardiology,Primary Care, or Nephrology • Patient is scheduled into a general cardiology,nephrology, or primary care template with a specificpostpartum hypertension visit type. • To facilitate clinic slots to accommodate postpartumpatients, these visit slots are reserved for patients whomeet specific criteria, including hypertensive disorderof pregnancy diagnosis. Staffing Several staffing models exist and can be individualized todifferent practice settings. Different staffing models mayrequire a nuanced approach at individual institutions. • A physician performs the initial new patient visit. • An advanced practice provider, typically trained inwomen’s health or cardio-obstetrics, may perform theinitial new patient visit or follow-up visits. This modelmay work better for clinics with limited physicianaccess due to staffing issues or remote locations. ### Page 13 • A dedicated nurse or clinical pharmacist can provideadditional support to see all patients and collectmedical history and demographic information. Thesedata can also be obtained digitally via questionnairesahead of visits to reduce administrative burdens. • Pharmacist services can support with medicationseducation, access, monitoring, and dose adjustment b. Types of visits Clinics offer in-person and virtual visits. Virtual visits are desirable and convenient forpostpartum patients. • Patient may be scheduled for a virtual visit if theyrequest it or if the patient faces barriers to making in-person visits due to financial restraints, geographicaldistance, transportation or childcare hurdles. • Patients scheduled for a virtual visit should have a homeblood pressure cuff and should be asked to check bloodpressure at home prior to the day of the appointment(ideally have 2 weeks of at least daily blood pressuremeasurements based on current ACC/AHA bloodpressure guideline recommendations once stable). Home visits have not been well studied in thepostpartum hypertension space, however they may offeran opportunity to optimize convenience for patients. Shared medical appointments (SMA): Patient isscheduled for a group visit (8-10 patients simultaneously)in a postpartum heart/cardiometabolic clinic between2-6 weeks postpartum • SMA visits are 90mins in length, which includesindividual patient encounters and a group educationalprogram on future cardiovascular risk related toadverse pregnancy outcomes (APOs) and counselingon lifestyle behaviors tomitigate CV risk. • The SMA model requires aconference/meeting roomwith areas for individualexams OR clinic spacewith several exam roomsavailable to accommodatesimultaneous appointmentsand a common conference/meeting room forgroup education. Alternatively, SMAs could beconducted virtually with separate ‘breakout rooms’ forindividualized management. • The SMA requires a standardized privacy form tomaintain HIPAA compliance. Patients must agree to notshare the personal information of other group members. PART II 1. Clinical models/operations ### Page 14 • During individual exams, anti-hypertensivemedications are adjusted, cardiac imaging isreviewed/ordered, and risk-stratification labs arerequested. • During group education, HDP association withcardiovascular risk is reviewed in-depth with a focus onrisk-reduction strategies through lifestyle and behaviormodifications. Visual presentation componentsand open questions and answers can enhance theeducational content and promote active participationin learning. This also reduces repetition for the primaryprovider/facilitator, as the content is delivered justonce to all participants simultaneously. • The Primary Provider can bill for each patient theypersonally perform a history and physical examinationon, coded to reflect the complexity of the visit. Theymay also bill for supervision of individual exams byadvanced practice providers serving as facilitators. • SMA sessions can provide a sense of communityfor participants who may be experiencing mood oradjustment disorders following a complicated delivery. c. Timing of visit Optimal visit timing will depend on the goals ofthe clinic, staffing model, and patient needs andpreferences. Referrals are accepted at any pointpostpartum in most programs (figure). Early postpartum visits (within 2 weeks) focus on earlyblood pressure management and medication titration. Patients being discharged on an anti-hypertensivemedication or with severe hypertension should bescheduled for a visit within 72 hours of discharge (typicallywith a member of the obstetrics care team, can be virtual) PART II 1. Clinical models/operations Postpartum Management Timeline Delivery Longitudinal primary care/subspecialty follow-up HBPM 6-week OB visit Early PP visit 1-2 weeks Late PP visit 6 weeks – 1 year Visit goals: BP management, lifestyle counseling,CV risk assessment, primary care transition Visit goal: BP management ### Page 15 ACOG recommends a blood pressure check and visitwithin 7 to 10 days of delivery for high-risk individuals Later postpartum visits (2 weeks to 1 year postpartum)focus on blood pressure management, lifestyleoptimization, cardiovascular risk assessment, andtransition to primary care. Patients living in states without Medicaid expansionbeyond the typical 6-week postpartum time period maybenefit from visits scheduled within 6 weeks of delivery. For list of resources on Medicaid expansion by stateplease see the following: ACOG:[https://www.acog.org/advocacy/policy-priorities/extend-postpartum-medicaid-coverage](https://urldefense.com/v3/__https:/www.acog.org/advocacy/policy-priorities/extend-postpartum-medicaid-coverage__;!!NHLzug!N7FV_6vyqDBIUC59OwCCDJdd_Xn3GgzgBjoHx8Z1qK9lzsaLbCFxbxSifCjKoi1cWn07B3g8Y0jbL36GZUzeaZleljLcvzIg7YWl5ubs$) KFF:[https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/](https://urldefense.com/v3/__https:/www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/__;!!NHLzug!N7FV_6vyqDBIUC59OwCCDJdd_Xn3GgzgBjoHx8Z1qK9lzsaLbCFxbxSifCjKoi1cWn07B3g8Y0jbL36GZUzeaZleljLcvzIg7UOo68H5$) d. Follow-up visits Follow-up visits at postpartum hypertension clinics or withsubspecialty clinicians depend heavily on local capacity,i.e., clinician availability and patient acuity. Patientswith hypertensive disorders of pregnancy should followlongitudinally with a primary care provider who has beenprovided a copy of the discharge summary and postpartumclinic consult notes. For patients without an establishedprimary care provider, facilitation with warm hand offs to anew primary care provider may improve transition of care Example follow-up options: • Follow-up recommended with primary care clinician,unless they have another indication for subspecialtyfollow-up. • Follow-up recommended with specialty clinic(cardiologist, nephrologist, and/or obstetrician). Thesefollow-up visits can also occur with an advanced practiceprovider. • Follow-up recommended within specialty clinic,depending on indication of initial visit. Patientsmay continue to receive care in the postpartumhypertension clinic for ongoing blood pressuremanagement, evaluation of cardiac symptoms orfindings, or ongoing cardiac risk prevention as needed. e. Referrals General Guidelines It is important to incorporate shared decision makingto determine the best way to engage and schedule apatient (timing, virtual/in-person) • Some programs refer all patients with a hypertensivedisorder of pregnancy (including gestational hypertension,chronic hypertension, preeclampsia, and eclampsia), PART II 1. Clinical models/operations ### Page 16 whereas other refer only the highest-risk patients, suchas those with preeclampsia with severe features or thosedischarged on at least one antihypertensive medication. • Having medical staff discuss the clinic with the patientprior to discharge may help improve attendance. • Discharge summaries should be completed within 24hours of discharge to allow for effective postpartumfollow-up care and interdisciplinary communication. • Postpartum navigators (doula, nurse, community healthworker) can be advantageous for helping patients navigatepostpartum systems including scheduling appointmentsand initiating in postpartum remote monitoring programs. Types of referrals Automated/default referral at the time of discharge fromdelivery hospitalization (preferred) • Patients may be scheduled prior to hospital discharge: This can be facilitated by an electronic healthrecord order that automatically goes to a schedulerand provides a time back to the ordering team forincorporation into discharge paperwork • Some clinics give patients the option to opt-out of the clinicby signing the bottom of the referral form prior to discharge(https://www.themothersprogram.ca/for-care-providers/the-postpartum-maternal-health-clinic-handbookc). • Eligible patients may also be identified through systematicchart review (example: for those who remain onantihypertensive medication) and may be contacted afterdischarge to schedule an appointment. This may be morefeasible for clinics embedded into an established remoteblood pressure monitoring or research program. Clinician referral • Obstetrics, primary care, or cardiology teams can referfrom hospital or post-partum visit as needed. • Electronic medical record order – specific postpartumhypertension clinic • Contact postpartum hypertension clinic staff for scheduling Patient self-referral • Patients are given information about the clinic withinstructions on how to self-schedule a visit. Patientoutreach consists of a brochure that can be given duringtheir hospitalization, or a text message delivered as part ofa remote BP monitoring program, which may also includea link to a brief video that provides education and clinicinformation. • Patients may find information online (through institutionwebsites or advertisements about the clinic) and self-refer PART II 1. Clinical models/operations ### Page 17 • Blood pressure measurement • Weight and waist circumference measurement (maybe sensitive to postpartum individuals) • Assess obstetric history, contraception, andbreastfeeding status • Assess mental health using validated screening tools(PHQ-9, GAD-7) • Assess social determinants of health • Blood testing Lipid profile to be performed after 12 weeks postpartum,if not performed in the year prior to pregnancy Diabetes screening: oral glucose tolerance test(within 12 weeks of delivery), fasting glucose, orHbA1c if seen later in postpartum period, if notperformed in early prenatal period Some clinics routinely order HbA1c, lipid profile,high sensitivity CRP, creatinine and a urinalysis(microalbumin creatinine ratio) Patients who do not complete recommendedblood work within 8 weeks of their appointmentcan be sent reminders • Cardiac testing (echocardiogram, cardiac CT, coronaryartery calcium score, stress test) should be ordered onan as-needed basis • Referrals should be generated as needed and can beconsidered for: Dietician Weight loss center Nephrology Endocrinology Mental and Behavioral health Lactation Social work • Estimate of 10-year (if over age 40), 30-year, orlifetime risk of cardiovascular disease • Assessment of cardiovascular risk factors • Blood pressure and other preventive medicationmanagement • Review medication safety • Counseling Education about best practices in home bloodpressure monitoring Symptoms of heart failure, stroke, myocardialinfarction, and postpartum preeclampsia Heart healthy lifestyle counseling using ACC’sHeart Healthy or AHA Life’s Essential 8 framework PART II 2. Clinic activities ### Page 18 Coding options based on Clinic structure: Multidisciplinary clinic model, combined coding Cardiology/primary care/nephrology and obstetrics/maternal fetal medicine at same visit • Patient is seen by both an internal medicine specialist orsubspecialist and obstetrician/maternal fetal medicine • Coding is for a single subspecialist visit, billed toreflect time and intensity of the visit. • One subspecialist department bill for each patient.Every other patient is scheduled on either the internalmedicine subspecialists OR obstetrician department,such that each department would bill for 4 or 5 patientsper clinic session (half of the 8-10 scheduled patients). • Each subspecialist documents separate note, butwithin the same encounter and one combined consultletter is sent to PCP, obstetrician, and referringprovider. Multidisciplinary clinic model, separate coding Cardiology/primary care/nephrology and obstetrics/maternal fetal medicine at same visit or separatevisit dates • The patient is scheduled and seen separately by internalmedicine specialist or subspecialist and obstetrician. • For the internal medicine specialist/subspecialist,coding is often time-based to reflect the intensity of thevisit or can use medical decision-making-based codes. • For the obstetrician, coding and billing may bewrapped into a postpartum bundle or, if seen beyond6 weeks postpartum, should be reflective of time andintensity of the visit. Specialized postpartum clinic, located withinObstetric clinic • Patients is scheduled into a dedicated postpartumclinic located in the obstetrics clinic • Coding and billing may be wrapped into a postpartumbundle or is time-based to reflect the intensity of thevisit or can use medical decision-making-based codes. Cardiology clinic, located within Cardiology/PrimaryCare/Nephrology clinic space • Patients are scheduled into a general cardiologytemplate. • Coding is often time-based to reflect the intensityof the visit or can use medical decision-makingbased codes. PART II 3. Coding and billing ### Page 19 Billing Codes: Clinic billing • Professional fees are billed to the patient’s insurance. • Relevant ICD-10 codes I10.0 Essential hypertension I11 Hypertensive heart disease I10.11 Malignant essential hypertension I15 Secondary hypertension E11.0 Diabetes with hypertension I12 Hypertension and CKD O11.9 Chronic HTN with superimposed preeclampsia 013.3 Gestational hypertension Z87.59 History of gestational hypertension 014* Preeclampsia (with multiple specific codesrelated to the timing of gestation, andcomplications such as HELLP) 014.90 Unspecified preeclampsia, unspecifiedtrimester O14.94 Unspecified preeclampsia, complicatingchildbirth O15* Eclampsia R03.0 Elevated BP without a diagnosis of hypertension Z13.6 Encounter for screening for cardiovasculardisorders Z30.09 Encounter for counseling regarding contraception Z31.69 Encounter for preconception consultation Z39.2 Postpartum state Z71.89 Cardiac risk counseling For further information regarding ICD-10 Billing codes:[https://www.cms.gov/Medicare/Coding/ICD10](https://www.cms.gov/Medicare/Coding/ICD10) Coding and billing for remote blood pressuremonitoring • Self-Measured Blood Pressure (SMBP) Codes andDescription: For clinics with remote blood pressure monitoringor blood pressure texting programs, additionalbilling via a telemedicine visit can be submitted.Note that these billing codes may not be applicablefor individuals insured by Medicaid in certain states. Code 99473 SMBP using a device validatedfor clinical accuracy; patient education/trainingand device calibration. This code may be usedwhen a patient receives education and training(facilitated by clinical staff) on the set-up and use,and can only be reported once per device. Code 99474 This code may be used for datacollection and interpretation in the followingscenarios: • Patient submits 12 blood pressure readings(separate self-measurements of two readingsone minute apart, twice daily over a 30-dayperiod (minimum of 12 Readings), or PART II 3. Coding and Billing ### Page 20 • Based on these documented blood pressurereadings the physician or other qualifiedhealth care professional creates or modifiesthe treatment plan. The treatment plan mustbe documented in the medical record andcommunicated back to the patient, eitherdirectly or through clinical staff. Remote physiologic monitoring codesand descriptions • These are other digitally stored data/remotephysiologic monitoring CPT codes that can be usedfor SMBP. Remote physiologic monitoring (RPM)codes are for collecting and interpreting physiologicdata that is digitally stored and/or transmitted by thepatient and/or caregiver to the physician or qualifiedhealthcare professional. • Code Description Code 99453 Remote monitoring of physiologicparameter(s) (e.g., weight, blood pressure, pulseoximetry, respiratory flow rate), initial; set-up andpatient education on use of equipment Code 99454 Device(s) supply with daily recording(s)or programmed alert(s) transmission, each 30 days Code 99457 Remote physiologic monitoringtreatment management services, 20 minutes ormore of clinical staff/physician/other qualifiedhealthcare professional time in a calendar monthrequiring interactive communication with thepatient/caregiver during the month Code 99458 Remote physiologic monitoringtreatment management services, clinical staff/physician/other qualified health care professionaltime in a calendar month requiring interactivecommunication with the patient/caregiver duringthe month; additional 20 minutes Code 99091 Collection and interpretation ofphysiologic data (e.g. ECG, blood pressure, glucosemonitoring) digitally stored and/or transmitted bythe patient and/or caregiver to the physician orother qualified healthcare professional, qualifiedby education, training, licensure/regulation (whenapplicable) requiring a minimum of 30 minutes oftime, each 30 days For more information, please refer to this handout fromthe AMA: https://www.ama-assn.org/delivering-care/hypertension/7-step-smbp-quick-guide-coding#:~:text=CPT%20code%2099474%20can%20be,readings%20required%20each%20billing%20period. PART II 3. Coding and Billing ### Page 21 Provision of effective contraception is stronglyrecommended for all pregnancy capable patients beingprescribed teratogenic medications which includean angiotensin-converting-enzyme (ACE) inhibitor,angiotensin receptor blocker (ARB), or mineralocorticoidreceptor antagonist. Because of their excellent safety andefficacy, long-acting reversible contraceptives are stronglyrecommended in appropriate candidates. Specifically,intrauterine devices and progesterone subdermalimplants are not contraindicated in patients withhypertension. Contraceptive methods are organized intothree tiers based on their failure rates with typical use: Tier I:* Failure rate <1% Long-acting reversible contraceptives: • Copper Intrauterine Device (IUD) • Etonogestrel subdermal Implant • Levonorgestrel Intrauterine Device (IUD) Permanent sterilization: • Male sterilization • Tubal Ligation Tier II: Failure Rate 6-12% Combined Hormonal Contraceptive (CHC) Pill** Depot Medroxyprogesterone Injection* Diaphragm* Progestin Only Pill* Transdermal Patch** Vaginal Ring** Tier III:* Failure Rate 18-28% Barrier methods Fertility awareness method / natural family planning Spermicide Withdrawal *No contraindications in hypertension Part III Obstetric considerations afterhypertensive disorders of pregnancy 1. Contraception 21 ### Page 22 ** Absolute contraindication in those with uncontrolledHTN (BP ³ 160/10 mmHg). Caution should be exercisedwhen using CHCs in persons with hypertension with a BP >140/90 mmHg. Increased risk of thromboembolism amongCHC users, transdermal patch, and vaginal ring amongthose with hypertension, tobacco use, and age >35. For additional information, please see our contraceptionAppendix or any of the following resources. Resources on contraception options: Lindley KJ, Bairey Merz CN, Davis MB, Madden T, Park K,Bello NA; American College of Cardiology CardiovascularDisease in Women Committee and the Cardio-ObstetricsWork Group. Contraception and Reproductive Planning forWomen With Cardiovascular Disease: JACC Focus Seminar5/5. J Am Coll Cardiol. 2021 Apr 13;77(14):1823-1834.doi: 10.1016/j.jacc.2021.02.025. PMID: 33832608; PMCID:PMC8041063. [https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf](https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf) Cameron N, Blyler CA, Bello NA. Oral Contraceptive Pillsand Hypertension: A Review of Current Evidence andRecommendations. Hypertension. Online ahead of printFebruary 2023. [http://www.reproductiveaccess.org/wp-content/uploads/2014/06/2020-09-contra-choices.pdf](http://www.reproductiveaccess.org/wp-content/uploads/2014/06/2020-09-contra-choices.pdf) PART III 1. Contraception 2. Pregnancy and delivery debriefing Patients with hypertensive disorders of pregnancy oftendeliver preterm and have traumatic birthing experiences.The postpartum hypertension clinic can provide a spaceto debrief some of the complications related to havinghad a hypertensive disorder of pregnancy. Often patientsmay need referral to behavioral health specialists,particularly in the setting of fetal complications whichcan include neonatal ICU admission and fetal demise.Clinicians should be sensitive to the possibility of fetal/neonatal demise and when appropriate inquire about thehealth of patients’ babies and provide compassionatecare during the vulnerable postpartum period. If thebaby is still in the neonatal ICU, appointments in theearly postpartum setting are often more convenient forpatients who are often visiting the medical center on adaily basis. ### Page 23 3. Screening for depression Screening for depression and anxiety in all individuals inthe postpartum period is critical to ensure appropriatediagnosis and referral for treatment. Screening can bedone using the Edinburgh Postnatal Depression Scale([https://perinatology.com/calculators/Edinburgh%20](https://perinatology.com/calculators/Edinburgh%20Depression%20Scale.htm)[Depression%20Scale.htm](https://perinatology.com/calculators/Edinburgh%20Depression%20Scale.htm)), which is available in over 50languages and is easy to score. Individuals who have apositive screen should be referred to behavioral health forfurther management. 4. Risk of recurrence The risk of recurrence for any hypertensive disorder ofpregnancy is around 21%. Concomitant HELLP syndromeor small for gestational age infant increase that risk.For individuals with a history of a hypertensive disorderof pregnancy, low dose aspirin should be given insubsequent pregnancies starting at 12 weeks to reducethe risk of preterm preeclampsia. Source: van Oostwaard MF, Langenveld J, Schuit E, et al. Recurrenceof hypertensive disorders of pregnancy: an individualpatient data metaanalysis. Am J Obstet Gynecol. 2015May;212(5):624.e1-17. doi: 10.1016/j.ajog.2015.01.009.Epub 2015 Jan 9. Erratum in: Am J Obstet Gynecol. 2015Sep;213(3):400. PMID: 25582098. PART III ### Page 24 Part IV Postpartum blood pressuremanagement 1. Postpartum Hypertension: Medication Titration Approach to Initiation Postpartum patients who were on antihypertensiveagents PRIOR to pregnancy: • Restart their home regimen prior to discharge,provided they are in line with patient’s breastfeedingand contraception plans (i.e. potential teratogenicity ofACE inhibitor and angiotensin receptor blocker (ARB)should be discussed and patients on these medicationsshould ideally have reliable forms of contraception) Postpartum patients NOT on antihypertensive therapy: • If SBP ≥ 140mmHg and or DBP ≥ 90mmHg on 2+occasions* (or alternative threshold per institution)START THERAPY *In the first 2 weeks postpartum, elevated BP should beconfirmed with at least 2 measurements > 4 hours apart Selecting Antihypertensive Medications:(see table) First-line agents, regardless of breastfeeding status: 1) Nifedipine 30mg XL daily or amlodipine 5mg daily • Better adherence with once daily dosing regimen • In line with ACC/AHA recommendation that acalcium channel blocker should be one of the firstline agents for hypertension management • Contraindications: known hypersensitivity reaction,heart failure with reduced ejection fraction,unstable angina 2) Enalapril 5mg daily (especially for those withpregestational diabetes) • In line with ACC/AHA’s recommendations thatACE inhibitor should be considered as first linetherapy in diabetic patients with hypertension • Can increase to BID dosing if needed • Contraindications: history of angioedema withACE inhibitor, pregnancy (counsel patients oncontraception and document plan) • Increased risk of hyperkalemia, consider checkingbasic metabolic panel after initiation if patient athigh risk for hyperkalemia 24 ### Page 25 • Avoid initiation in patients with evidence of acutekidney injury. Although there is no creatinine at whichACE inhibitor is absolutely contraindicated, the risk ofhyperkalemia may outweigh the potential benefits ofthe agent. 3) Labetalol 100mg two or three times daily • Commonly used during pregnancy and postpartumwith good safety data • Requires at least BID dosing, more typically TID or QID • Disadvantage of more challenging dosing regimen Second-line agents: If breastfeeding: hydrochlorothiazide, carvedilol,spironolactone, furosemide If not breastfeeding: Chlorthalidone, ACE inhibitor(besides enalapril), ARB Important caveats when initiatingantihypertensives: Provision of effective contraception is strongly recommendedfor all patients prescribed an ACE inhibitor, ARB, angiotensinreceptor blocker neprilysin inhibitor (ARNI), or mineralocorticoidreceptor antagonist (MRA) who are capable of pregnancy. When starting ACE inhibitor/ARB – ensure they havereceived counseling on ACE inhibitor and contraindicationto pregnancy and have a documented birth control plan. While enalapril is considered safe with lactation, cautionshould be exercised in mothers who are breastfeeding prematureinfants with underdeveloped nephrons given the risk of renaltoxicity. This is particularly important in mothers requiring higherdoses of enalapril. While hydrochlorothiazide and furosemide are safe withlactation, diuretics may decrease breastmilk production ina dose-dependent fashion. Hydrochlorothiazide is unlikelyto decrease breastmilk production at doses of 25mg or lessper day while furosemide is unlikely to decrease breastmilkproduction at doses of 20mg or less per day. In the early postpartum period, the patient’s obstetric teammay manage hypertension. It is appropriate to transition tocardiology or primary care management of blood pressureat any point between 0 and 12 weeks postpartum. Typically,this transition occurs sometime between weeks 2-6,depending on the institution. If blood pressure is sustained >= 160/110 mmHg or>=160/110mmHg with associated symptoms In thepostpartum period (<6 weeks after delivery), patients shouldbe triaged to be seen in an obstetrics maternal evaluationunit or emergency room to reduce the risk of stroke orother significant morbidity or mortality. In the immediatepostpartum period, evaluation for postpartum preeclampsiashould be urgently undertaken. PART IV 1. Postpartum Hypertension: Medication Titration ### Page 26 PART IV 1. Postpartum Hypertension: Medication Titration Medication Therapy Options | Drug Name and Class | Starting Dose | Maximum Dose | Titration Intervalin Stable Patients | Lactation Safety | | - | - | - | - | - | | First-line agents | | Nifedipine XL (CCB) | 30mg daily | 120mg/day or 60 mg BID | Q5-7 days | SAFE RID 2.3-3.4% | | Enalapril (ACEi) | 5mg daily | 40mg/day or 20mg BID | Q5-7 days | SAFE RID 1.1% | | Amlodipine (CCB) | 5mg daily | 10mg/day | Q5-7 days | SAFE RID 1.7-4.3% | | Labetalol (beta blocker) | 200mg TID | 2400mg/day | Q2-3 days | SAFE RID 3.6% | | Alternative agents | | Hydrochlorothiazide(thiazide diuretic) | 12.5mg daily | 50mg/day | Q3-5 days | SAFE RID 0.6-1.2%May decrease breastmilk production (dose >25mg/day) | | Furosemide (loop diuretic) | 10mg daily | 160mg per day (can beBID, TID dosing) | Q3-5 days | SAFE May decrease breastmilk production (dose >20 mg/day) | | Hydralazine (direct vasodilator) | 10mg QID | 200mg/day | Q2-3 days | SAFE RID 0.77-3% | | Spironolactone (MRA) | 12.5mg daily | N/A | Q14-30 days | SAFE RID 2-4.3% | | Verapamil (CCB) | 80mg daily | 360mg daily | Q5-7 days | SAFE RID <1% | | Carvedilol (beta blocker) | 6.25 mg BID | 25mg BID (or 50mg BID ifweight >100kg) | Q2-3 days | Limited safety data, likely low risk | | Metoprolol tartrate (beta blocker) | 12.5mg BID | 200mg BID | Q2-3days | Limited safety data, likely low risk | | Bisoprolol (beta blocker) | 2.5mg daily | 20mg/day | Q5-7 days | Limited safety data | | Chlorthalidone (thiazide diuretic) | 12.5 mg daily | 100mg/day | Q7-14 days | RID 1.9-18.1% Present in breast milk, may decreasebreastmilk production | | Eplerenone (MRA) | 25mg daily | N/A | Q14-30 days | RID 0.01-3.39% Limited safety data | | Lisinopril (ACEi) | 2.5mg daily | 40mg/day | Q5-7 days | Limited safety data | | Losartan (ARB) | 25mg daily | 100mg/day | Q5-7 days | Limited safety data | | Valsartan (ARB) | 20mg daily | 320mg/day | Q5-7 days | Limited safety data | | Clonidine (alpha antagonist) | 0.1mg BID, or 0.1mgpatch weekly | 2.4mg PO total daily, ortwo 0.3mg patch/24hrs | Q7 days | RID 0.9-7.1% Limited safety data, present in breastmilkand likely negatively affects lactation | * RID stands for the relative infant dose and indicates lactational safety. RID levels < 10% are considered safe. Hale’s Medications & Mothers’ Milk Online Consultant was used to extrapolate RID%.This resource provides RID calculations which are based on studies that consist of larger data (+/- AUC) and is weight-normalized (when weight provided). If maternal weights were not published,70kg average body weight was used in calculations and daily milk intake of 150mL/kg/day by infant. ### Page 27 PART IV 1. Postpartum Hypertension: Medication Titration Approach to Medication Titration Goal blood pressure: average < 140/90 mmHg early postpartum, then < 130/80 mmHg longitudinally* Monitor BP 1-2x/day in the first 2 weeks postpartum If well controlled, space out measurements to 2-3x/week If SBP> 160 mmHg orDBP> 110 mmHg on 2 separate readings,sustained over 15minutes AND/ORif patient developspersistent headache,severe abdominal pain,shortness of breath, orvision changes – Patient shouldCONTACT physicianand undergo urgentassessment If average SBP> 140mmHg or DBP> 90mmHg, and SBP< 160 orDBP 110 mmHg Initiate/Increaseantihypertensivemedications If average SBP < 140mmHg and DBP < 90mmHg but > 120/70mmHg Continue currentantihypertensivemedications If average SBP< 110-120mmHg and DBP< 60-70mmHg Start decreasingantihypertensivemedications in reverseorder of up titration *Approach to medication titration and blood pressure goals should be discussedwith obstetrician and maternal fetal medicine colleagues at your institution. Optimalblood pressure goals throughout the 4th trimester is currently an evidence-free spaceand different guidelines may depend on clinic and remote blood pressure monitoringmodels b institution. ### Page 28 PART IV 1. Postpartum Hypertension: Medication Titration Recommended approach to increasing medications in stable patients Initial dose: Nifedipine XL 30mg daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 5-7 days, increase to 60mg daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 5-7 days, increase to 90mg daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 5-7 days, add second antihypertensive agent OR Increase to max dose 120mg daily or 60mg twice daily Initial dose: Enalapril 5mg daily or 2.5mg twice daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 5-7 days, can double dose to 10mg daily or 5mg twice daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 5-7 days, can double dose to 20mg daily or 10mg twice daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 5-7 days, consider addition of second antihypertensive agent OR Increase to max dose 40mg daily or 20mg twice daily Initial dose: Amlodipine 5mg daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 5-7 days, increase to 10mg daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 5-7 days, add second antihypertensive agent OR Initial dose: Labetalol 100mg or 200mg three times daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 2-3 days, increase to 200mg or 300mg three times daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 2-3 days, increase to 400mg three times daily If BP SBP remains ≥ 140 or DBP ≥ 90 after 2-3 days, consider addition of second antihypertensive agent OR Increase dose in increments of 100mg three times daily (max 2400mg/day). If patient reports symptomssuggesting intolerance (i.e., headache, fatigue, hypotension) further titration should be limited ### Page 29 PART IV 1. Postpartum Hypertension: Medication Titration Recommended approach to decreasing medications If average BP < 110-120/60-70 mmHg: If on nifedipine, decrease by 30mg and if on 30mg HOLD and monitor for 1 week and call with status. OR If on labetalol, decrease by 100 or 200mg BID-TID (depending on desired BP change) OR If on both nifedipine and labetalol, start with decrease in nifedipine if dose >90mg; otherwise start withdecrease in labetalol as above OR If on carvedilol, decrease dose by half (i.e. decrease 12.5mg BID to 6.25mg BID) or hold if on 3.125mg OR If on enalapril daily or BID, decrease dose by half OR If on amlodipine, decrease dose by half ### Page 30 PART IV 2. Remote Blood Pressure Monitoring Programs There is robust evidence demonstrating the use ofhome blood pressure monitoring, or self-measuredblood pressure monitoring (SMBP), with clinical supportcan significantly lower blood pressure. The recentlypublished POP-HT trial showed the benefit of remoteblood pressure monitoring in reducing postpartumblood pressure.18 The use of these programs alongsidea postpartum hypertension clinic can help identifyhypertensive patients and make blood pressure controlmore convenient and accessible for patients. What is SMBP? One complete cycle of SMBP includesa minimum of 12 total blood pressure readings (separatemeasurements of two readings performed one minuteapart, twice daily) over a 30-day period. The averagesystolic and diastolic blood pressure is then calculatedfrom these data points and utilized as a diagnostic toolto drive treatment decisions. This cycle has been definedaccording to billing standards (ICD codes), but they maynot be applicable for individuals insured by Medicaid incertain states. Key elements: • Validated blood pressure device with appropriate-sized cuff (https://www.validatebp.org/) • Patient centered training on when and how toaccurately measure blood pressure (https://www.cardiosmart.org/topics/high-blood-pressure/assets/fact-sheet/how-to-take-your-blood-pressure-at-home) • Patient-facing application to log and transmit data tothe electronic medical record (texting, smart phoneapplication, website, manual entry into patient portal) • Clinical support team to review data and adjustmedications as needed • Algorithm to determine the frequency of data reviewand treatment titration Interface with the electronic medical record Many different data management solutions/technologypartners are available to review patient-generatedhealth data. There are some home blood pressuremeasurement devices which are capable of digitaldata storage and can transfer data through a cellularor internet network either to the patient’s smart deviceor to a secure cloud-based portal for use by the careteam. There are other software vendors which may offera variety of integration capabilities with the electronichealth record. Selection of specific software optionsshould be based on the desired requirements of eachclinic. Patients can also enter home blood pressures intohealth system patient portals. ### Page 31 Oversight team The remote blood pressure monitoring oversight team typicallyincludes a clinical support team (nurse, pharmacist, nursepractitioner) who can follow specific protocols for blood pressuremanagement in the postpartum period. Physician oversight canbe performed by obstetricians, cardiologists, or primary careclinicians. Frequency of monitoring In the early postpartum period, <2 weeks after delivery,most programs will recommend checking at least daily bloodpressures, often twice daily. After 2 weeks postpartum, candecrease frequency to once daily or a few times per week.Once established a steady state with stable blood pressuremeasurements, most programs will space out measurements to2-3 times per week. Length of program Many programs have remote blood pressure monitoring for 2-6weeks postpartum. Other programs extend up to 1 year postpartum.The duration of postpartum remote blood pressure monitoring isunique based on medical system factors and typically chosen basedon available resources to support the oversight team and plannedfollow-up time period. Often, remote blood pressure monitoringprograms are supported by hospitals or health care systems. PART IV 2. Remote Blood Pressure Monitoring Programs ### Page 32 Part V Clinic example documents,dot phrases, and other materials 1. Clinic notes **The following templates are formatted for Epic systems. Postpartum Clinic New Visit Postpartum Cardiovascular Clinic Provider: Patient Name:@NAME@ DOB:@DOB@ Date of Service:@ED@ Primary OB/GYN: *** PROBLEM LIST {1:1::”Hypertension”,”Chronic Hypertension with Superimposed Preeclampsia”,”Preeclampsia”,”Preeclampsiawith Severe Features”,”HELLP Syndrome”,”Eclampsia”,”Gestational Hypertension”} *** Today I had the pleasure of seeing @NAME@ at the *** Postpartum Cardiovascular Clinic forfollow up after her recent delivery complicated by {1:1::”Hypertension”,”Chronic Hypertensionwith Superimposed Preeclampsia”,”Preeclampsia”,”Preeclampsia with Severe Features”,”HELLPSyndrome”,”Eclampsia”,”Gestational Hypertension”}. She is now postpartum day # *** from a{1:1::”NSVD”,”operative vaginal delivery”,”Cesarean delivery”}. Delivery complications included: 32 ### Page 33 {1:1::”***”,”None”}. Baby {1:1::”has”,”has not”} been in the neonatal ICU. Discharge antihypertensive medications included: *** The following changes have been made to her medication regimen since discharge: {1:1::”none”,”***”} Medication Adherence: # of missed doses per week – {1:1::”<1 dose”,”1-3 doses”,”>3 doses”,”Not taking any ofher prescribed medications”,”N/A, no antihypertensive medications are prescribed”} Barriers to adherence include: *** She {1:1::”has”,”has not”} been enrolled in remote blood pressure monitoring. {1:1::”Home blood pressures havebeen ranging from ***.”,”She has not been checking her blood pressure at home.”} She {1:1::”has”,”has not”} been readmitted to the hospital since delivery. Reason for hospital readmission was:{1:1::”hypertension”,”heart failure”,”stroke/TIA”,”arrhythmia”,”seizure”,”hemorrhage”,”infection”,”N/A”,”***”} She reports the following cardiac symptoms since discharge.: Chest pain/pressure: {1:1::”yes”,”no”} Shortness of breath/DOE: {1:1::”yes”,”no”} PND: {1:1::”yes”,”no”} Orthopnea: {1:1::”yes”,”no”} Lower extremity edema: {1:1::”yes”,”no”} Cough: {1:1::”yes”,”no”} Headache: {1:1::”yes”,”no”} Visual changes: {1:1::”yes”,”no”} She {1:1::”is”,”is not”} breastfeeding. She has chosen the following for contraception: *** PART V 1. Clinic notes: Postpartum Clinic New Visit ### Page 34 PAST MEDICAL HISTORY Thyroid Disorder: {1:1::”yes”,”no”} Depression/Anxiety/Mental Illness: {1:1::”yes”,”no”} Diabetes: {1:1::”yes”,”no”} DVT/PE: {1:1::”yes”,”no”} Hypertension: {1:1::”yes”,”no”} Autoimmune Disorder: {1:1::”yes”,”no”} Hyperlipidemia: {1:1::”yes”,”no”} Lupus/SLE: {1:1::”yes”,”no”} CKD: {1:1::”yes”,”no”} Asthma: {1:1::”yes”,”no”} Infectious Disease (HIV, Hep B, Hep C):{1:1::”yes”,”no”} Arrhythmia: {1:1::”yes”,”no”} Seizure Disorder: {1:1::”yes”,”no”} Cancer: {1:1::”yes”,”no”} Sickle Cell Disease:{1:1::”yes”,”no”} Obesity: {1:1::”yes”,”no”} Migraines: {1:1::”yes”,”no”} OSA:{1:1::”yes”,”no”} CAD/MI: {1:1::”yes”,”no”} CHF: {1:1::”yes”,”no”} Other: {1:1::”yes”,”no”} Stroke: {1:1::”yes”,”no”} PAST OBSTETRIC HISTORY G***P*** Prior Preeclampsia: {1:1::”yes”,”no”} Prior Gestational Hypertension: {1:1::”yes”,”no”} Prior Gestational Diabetes: {1:1::”yes”,”no”} Preterm Birth: {1:1::”yes”,”no”} Fetal growth restriction or small for gestational age: {1:1::”yes”,”no”} Large for gestational age: {1:1::”yes”,”no”} Miscarriage/spontaneous abortion: {1:1::”yes”,”no”} Stillbirth/Intrauterine fetal demise: {1:1::”yes”,”no”} Placental abruption: {1:1::”yes”,”no”} MEDICATIONS @ENCMED@ ALLERGY @ALG@ PART V 1. Clinic notes: Postpartum Clinic New Visit ### Page 35 SOCIAL HISTORY Education: *** Occupation: *** Marital Status: *** Activity Level: {1:1::”Sedentary”,”Moderately Active”,”Active”} Tobacco: {1:1::”Current - *** PPD”,”Former”,”Never”} Drugs: {1:1::”Current”,”Former”,”Never”} If yes, Type: {1:1::”***”,”N/A”} Alcohol: {1:1::”Current”,”Former”,”Never”} FAMILY HISTORY Sudden death:{1:1::”yes”,”no”} CAD: {1:1::”yes”,”no”} Stroke: {1:1::”yes”,”no”} MI: {1:1::”yes”,”no”} CHF: {1:1::”yes”,”no”} DM:{1:1::”yes”,”no”} HTN: {1:1::”yes”,”no”} PVD: {1:1::”yes”,”no”} Dyslipidemia:{1:1::”yes”,”no”} Arrhythmia: {1:1::”yes”,”no”} REVIEW OF SYSTEMS {x:19197::”Review of systems per HPI and otherwise all other review of systems negative.”,”Unable to obtain due to ***”} PHYSICAL EXAM @VS@ PART V 1. Clinic notes: Postpartum Clinic New Visit ### Page 36 Edinburgh Depression Score: *** Vital signs, weight, and intake/output reviewed. Gen: well developed, well nourished, no acute distress HEENT: moist mucus membranes, no jugular venous distension, no carotid bruits Chest: Lungs clear to auscultation bilaterally Cardiac: Regular rate and rhythm, no murmurs/gallops/rubs Abdomen: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly Extremities: Warm and well-perfused, positive pulses, no cyanosis, clubbing, or edema Skin: No rashes Neurologic: nonfocal exam Psychiatric: alert and oriented DIAGNOSTIC DATA @RESULAST(sodium:1,kplasma:1,potassium:1,creatinine:3)@ @RESULAST(hgb:2)@ @RESULAST(tsh:1)@ @RESULAST(chol:1,trig:1,hdl:1,ldlcalc:1)@ @RESULAST(ntprobnp:1)@ @RESULAST(hba1c:1)@ EKG: *** TTE: *** PART V 1. Clinic notes: Postpartum Clinic New Visit ### Page 37 ASSESSMENT & PLAN 1) History of {1:1::”Hypertension”,”Chronic Hypertension withSuperimposed Preeclampsia”,”Preeclampsia”,”Preeclampsiawith Severe Features”,”HELLPSyndrome”,”Eclampsia”,”Gestational Hypertension”} – Blood pressure today is {1:1::”at goal”,”above goal”,”low”}.Goal blood pressure <130/80 mmHg. The followingmedication adjustments were made: • {1:1::”none”,”***”}. • If BP trends down (average < 130/80), will plan todecrease medications starting with__ • She was counseled to check home blood pressures dailyand call with any symptoms of headache, visual changes,dyspnea, pnd, orthopnea, worsening edema, chest pain,lightheadedness/syncope, or palpitations. • She was counseled to call with any blood pressure>160/100 or <100 systolic. • Encouraged low sodium, DASH diet (provided information) 2) Future cardiovascular risk with history of preeclampsia/hypertensive disorder of pregnancy: A history of preeclampsiais associated with an increased risk of hypertension and futurecardiovascular disease including hypertension, coronary arterydisease, heart failure, and stroke. Severe preeclampsia caries aneven greater risk, with about 50% of patients developing stage Ihypertension at one year after delivery. We discussed these riskstoday and recommend the following for aggressive cardiovascularrisk factor screening and modification. We discussed theimportance of lifelong annual blood pressure monitoring. • Blood pressure management as above • Cholesterol and diabetes screening (FBG at 6 weeks andlipid screening 12 weeks after delivery.) • Encouraged diet and exercise to achieve a BMI less than 25 • Advised regular exercise regimen - at least 30 minutes ofmoderate activity 5 times a week 3) Pregnancy Planning – The benefits of LARC have beendiscussed. She has chosen the following for contraception: ***and is/is not interested in future pregnancies. We discussedthat she is at risk for preeclampsia in future pregnancies andwe would recommend ASA for preeclampsia prophylaxisshould she become pregnant again in the future. I have spent more than *** minutes caring for pt today of which50% of time was spent in counseling. Thank you very much for letting me participate in the careof this patient. I will plan to see her back at the PostpartumCardiovascular Clinic in follow up in ***. Please feel free to call withany questions or concerns. Sincerely, @SIGENC@ PART V 1. Clinic notes: Postpartum Clinic New Visit ### Page 38 New Postpartum Telehealth Visit Postpartum Cardiovascular Clinic Provider: Patient Name:@NAME@ DOB:@DOB@ Date of Service:@ED@ Primary OB/GYN: *** This was a telemedicine visit with @NAME@ which took place via {AMB METHOD OF COMMUNICATION:39852}.During the visit, I was located at { ***”remote office via secure VPN”} and the patient was located {1:1::”at home”, “atwork”} in {1:1::”TN, “MO”, “IL”, “KY”}. The session started at *** and ended at ***. The patient has been informed that the visit may not be secure and acknowledged the information. After being given an opportunity to ask questions about and discuss this type of visit, the patient verbally consentedto proceeding with the telephone / video visit. The patient understands that this service replaces an office visit andthey may be billed and/or responsible for any applicable copayments. PROBLEM LIST {1:1::”Hypertension”,”Chronic Hypertension with Superimposed Preeclampsia”,”Preeclampsia”,”Preeclampsia withSevere Features”,”HELLP Syndrome”,”Eclampsia”,”Gestational Hypertension”} *** Today I had the pleasure of seeing @NAME@ at the *** Postpartum Cardiovascular Clinic for follow upafter her recent delivery complicated by {1:1::”Hypertension”,”Chronic Hypertension with SuperimposedPreeclampsia”,”Preeclampsia”,”Preeclampsia with Severe Features”,”HELLP Syndrome”,”Eclampsia”,”Gestational PART V 1. Clinic notes: New Postpartum Telehealth Visit ### Page 39 Hypertension”}. She is now postpartum day # *** from a {1:1::”NSVD”,”operative vaginal delivery”,”Cesareandelivery”}. Delivery complications included: {1:1::”***”,”None”}. Discharge antihypertensive medications included: *** The following changes have been made to her medication regimen since discharge: {1:1::”none”,”***”} Medication Adherence: # of missed doses per week – {1:1::”<1 dose”,”1-3 doses”,”>3 doses”,”Not taking any ofher prescribed medications”,”N/A, no antihypertensive medications are prescribed”} Barriers to adherence include: *** She {1:1::”has”,”has not”} been enrolled in remote blood pressure monitoring. {1:1::”Home blood pressures havebeen ranging from ***.”,”She has not been checking her blood pressure at home.”} She {1:1::”has”,”has not”} been readmitted to the hospital since delivery. Reason for hospital readmission was:{1:1::”hypertension”,”heart failure”,”stroke/TIA”,”arrhythmia”,”seizure”,”hemorrhage”,”infection”,”N/A”,”***”} She reports the following cardiac symptoms since discharge.: Chest pain/pressure: {1:1::”yes”,”no”} Shortness of breath/DOE: {1:1::”yes”,”no”} PND: {1:1::”yes”,”no”} Orthopnea: {1:1::”yes”,”no”} Lower extremity edema: {1:1::”yes”,”no”} Cough:{1:1::”yes”,”no”} Headache: {1:1::”yes”,”no”} Visual changes: {1:1::”yes”,”no”} She {1:1::”is”,”is not”} breastfeeding. She has chosen the following for contraception: *** PART V 1. Clinic notes: New Postpartum Telehealth Visit ### Page 40 PAST MEDICAL HISTORY Thyroid Disorder: {1:1::”yes”,”no”} Depression/Anxiety/Mental Illness: {1:1::”yes”,”no”} Diabetes: {1:1::”yes”,”no”}DVT/PE: {1:1::”yes”,”no”} Hypertension: {1:1::”yes”,”no”}Autoimmune Disorder: {1:1::”yes”,”no”} Hyperlipidemia: {1:1::”yes”,”no”} Lupus/SLE: {1:1::”yes”,”no”} CKD: {1:1::”yes”,”no”}Asthma: {1:1::”yes”,”no”} Infectious Disease (HIV, Hep B, Hep C):{1:1::”yes”,”no”}Arrhythmia: {1:1::”yes”,”no”} Seizure Disorder: {1:1::”yes”,”no”}Cancer: {1:1::”yes”,”no”} Sickle Cell Disease:{1:1::”yes”,”no”} Obesity: {1:1::”yes”,”no”} Migraines: {1:1::”yes”,”no”}OSA:{1:1::”yes”,”no”} CAD/MI: {1:1::”yes”,”no”} CHF: {1:1::”yes”,”no”} Other: {1:1::”yes”,”no”}Stroke: {1:1::”yes”,”no”} PAST OBSTETRIC HISTORY G***P*** Prior Preeclampsia: {1:1::”yes”,”no”} Prior Gestational Diabetes: {1:1::”yes”,”no”} Preterm Birth: {1:1::”yes”,”no”} IUGR/SGA: {1:1::”yes”,”no”} MEDICATIONS @ENCMED@ PART V 1. Clinic notes: New Postpartum Telehealth Visit ### Page 41 ALLERGY @ALG@ SOCIAL HISTORY Education: *** Occupation: *** Marital Status: *** Activity Level: {1:1::”Sedentary”,”Moderately Active”,”Active”} Tobacco: {1:1::”Current - *** PPD”,”Former”,”Never”} Drugs: {1:1::”Current”,”Former”,”Never”} If yes, Type: {1:1::”***”,”N/A”} Alcohol: {1:1::”Current”,”Former”,”Never”} FAMILY HISTORY Sudden death: {1:1::”yes”,”no”} CAD: {1:1::”yes”,”no”} Stroke: {1:1::”yes”,”no”} MI: {1:1::”yes”,”no”} CHF: {1:1::”yes”,”no”} DM:{1:1::”yes”,”no”} HTN: {1:1::”yes”,”no”} PVD: {1:1::”yes”,”no”} Dyslipidemia:{1:1::”yes”,”no”} Arrhythmia: {1:1::”yes”,”no”} REVIEW OF SYSTEMS {x:19197::”Review of systems per HPI and otherwise all other review of systems negative.”,”Unable to obtain due to ***”} PART V 1. Clinic notes: New Postpartum Telehealth Visit ### Page 42 PHYSICAL EXAM This was a telehealth visit. {1:1::”@VS@”,”Patient unable to obtain vital signs.”} DIAGNOSTIC DATA @RESULAST(sodium:1,kplasma:1,potassium:1,creatinine:3)@ @RESULAST(hgb:2)@ @RESULAST(tsh:1)@ @RESULAST(chol:1,trig:1,hdl:1,ldlcalc:1)@ @RESULAST(ntprobnp:1)@ @RESULAST(hba1c:1)@ EKG: *** TTE: *** ASSESSMENT & PLAN 4) History of {1:1::”Hypertension”,”Chronic Hypertension with Superimposed Preeclampsia”,”Preeclampsia”,”Preeclampsia with Severe Features”,”HELLP Syndrome”,”Eclampsia”,”Gestational Hypertension”} – Blood pressure today is {1:1::”at goal”,”above goal”,”low”}. Goal blood pressure <130/80 mmHg. The followingmedication adjustments were made: • {1:1::”none”,”***”}. • If BP trends down (average < 130/80), will plan to decrease medications starting with__ • She was counseled to check home blood pressures daily and call with any symptoms of headache, visual changes,dyspnea, pnd, orthopnea, worsening edema, chest pain, lightheadedness/syncope, or palpitations. • She was counseled to call with any blood pressure >160/100 or <100 systolic. • Encouraged low sodium, DASH diet (provided information) PART V 1. Clinic notes: New Postpartum Telehealth Visit ### Page 43 5) Future cardiovascular risk with history of preeclampsia/hypertensive disorder of pregnancy: A history ofpreeclampsia is associated with an increased risk of hypertension and future cardiovascular disease includinghypertension, coronary artery disease, heart failure, and stroke. Severe preeclampsia caries an even greater risk,with about 50% of patients developing stage I hypertension at one year after delivery. We discussed these riskstoday and recommend the following for aggressive cardiovascular risk factor screening and modification. Wediscussed the importance of lifelong annual blood pressure monitoring. • Blood pressure management as above • Cholesterol and diabetes screening (FBG at 6 weeks and lipid screening 12 weeks after delivery.) • Encouraged diet and exercise to achieve a BMI less than 25 • Advised regular exercise regimen - at least 30 minutes of moderate activity 5 times a week 6) Pregnancy Planning – The benefits of LARC have been discussed. She has chosen the following forcontraception: *** and is/is not interested in future pregnancies. We discussed that she is at risk for preeclampsiain future pregnancies and we would recommend ASA for preeclampsia prophylaxis should she become pregnantagain in the future. Thank you very much for letting me participate in the care of this patient. I will plan to see her back at the PostpartumCardiovascular Clinic in follow up in ***. Please feel free to call with any questions or concerns. Sincerely, @SIGENC@ PART V 1. Clinic notes: New Postpartum Telehealth Visit ### Page 44 Preeclampsia long term cardiovascular counseling Due to her prior history of ***, she is at increased risk for future cardiovascular events including coronary arterydisease, stroke, hypertension, and heart failure. I recommend annual blood pressure assessment and routine lipid anddiabetes screening per national guidelines. I recommend lifestyle modifications including diet and exercise to reducemodifiable risk factors for future cardiovascular events. Per the 2018 ACC/AHA lipid guidelines, it is reasonableto consider initiation of statin therapy in individuals >40 years of age when their calculated 10-year ASCVD(atherosclerotic cardiovascular disease) risk rises above 5% or if they have an additional indication for statin therapyincluding elevated LDL or concomitant dyslipidemia and diabetes. BP Counseling instructions Check blood pressure *** daily Call for {x:19197::”multiple blood pressures over 140 or any blood pressure over 160”,”***”} Call for any headache, vision changes, chest pain, or difficulty breathing Send in blood pressure log *** Order Favorites Lipid battery Hemoglobin A1C Basic metabolic panel Transthoracic echocardiogram Nutrition consult Pulmonary consult Bariatric surgery consult Cardiac rehab consult PART V 1. Clinic notes ### Page 45 SmartPhrase for Letter to Primary Care and Referring Physicians Dear ***, It was a pleasure to meet with your patient, @name@, at the Postpartum Hypertension Clinic, a multi-disciplinaryclinic dedicated to the care of individuals with hypertensive disorders of pregnancy. This letter is in follow-up to yourpatient’s recent visit following a pregnancy complicated by a hypertensive disorder. We know that the developmentof a hypertensive disorder of pregnancy is considered a pregnancy-related cardiovascular risk enhancer and helps toidentify individuals who are at future risk of developing cardiovascular disease such as heart attack, heart failure, orstroke. At the time your patient was seen, we recommended obtaining lab work including a lipid panel and hemoglobinA1C. We provide details on any additional cardiovascular risk factors that we identified in our attached notes. We discussed making lifestyle modifications to improve their cardiovascular risk. Specifically, we talked aboutincreasing baseline activity level and developing a regular exercise regimen. The American Heart Association(AHA) recommends at least 30 minutes of moderate intensity physical activity 5 days a week. We also discussedmaintenance of a healthy weight with a BMI of less than 25. We recommended a heart healthy diet. We stronglyencouraged complete cessation of all tobacco products. Please find the details of our discussion and recommendations in the attached copy of our visit note. If you would like more information related to pregnancy, the postpartum and future health, you can explore thefollowing website. Yours sincerely, Provider PART V 1. Clinic notes ### Page 46 Part VI Patient education Postpartum Hypertension: Patient Education Resources What is preeclampsia? Both during and after pregnancy a person’s heartgoes through many changes as more blood is neededto reach the baby and placenta. Many individualsdevelop issues with blood pressure related to thesechanges that can start during pregnancy or up to sixmonths after delivery. These blood pressure issuesrange from gestational hypertension, which is typicallya mild elevation in blood pressure, to preeclampsia oreclampsia, which can result in more severe elevationsin blood pressure. Preeclampsia and eclampsia arelife threatening conditions which can lead to seizures,stroke, multi-organ failure, or death of the motherand/or baby. It is important to know how to identifypreeclampsia and the spectrum of hypertensivedisorders of pregnancy. • • • Video: Hypertensive disorders of pregnancyand long-term cardiovascular risk Individuals who develop a hypertensive disorder ofpregnancy are at an increased risk of developinghigh blood pressure and future heart disease,which includes heart attack, stroke, and death fromcardiovascular causes. It is important to be aware ofthese risks and take preventative steps to avoid thedevelopment of such disorders. • • • • ### Page 47 How to measure and log blood pressure It is important to consistently and accurately check yourblood pressure in order to diagnose and manage ahypertensive disorder of pregnancy. Checking your bloodpressure requires that you have a working blood pressurecuff that has been validated (setup to have accuratereadings). The following resources include informationand guidance on blood pressure, how to measure bloodpressure, as well as a variety of blood pressure logs totrack your blood pressure at home: [ACC Blood PressureFactsheet](https://www.cardiosmart.org/topics/high-blood-pressure/assets/infographic/blood-pressure) Videos: Here are some helpful videos that highlight howto use a blood pressure cuff and specific details on how tomeasure blood pressure: Lifestyle approaches to managing blood pressure For patients who are interested in lifestyle changes toimprove their blood pressure postpartum, there areseveral online resources on diet and exercise. The National Institute of Health (NIH) has a detailedguide on lowering blood pressure with the DASH (DietApproaches to Stop Hypertension) diet that includes tipsfor gradual change, serving size guidelines, a meal andphysical activity tracker, and a sample meal plan. The American College of Obstetricians and Gynecologists(ACOG) provides a frequently asked questions page withguidelines on how to exercise in the postpartum period. The Centers for Disease Control and Prevention (CDC)also has brief guidelines on exercise during pregnancyand the postpartum period. PART VI Postpartum Hypertension: Patient Education Resources ### Page 48 The ACC and the American Heart Association (AHA) bothprovide general guidelines on how exercise can improveblood pressure. Although these resources are not specificto hypertensive disorders of pregnancy, they includegeneral guidance about the recommended amount ofexercise, practical tips for increasing physical activity, andthe estimated impact on blood pressure. [ACC’s Move More](https://www.cardiosmart.org/topics/healthy-living/move-more) The ACC and AHA have handouts with tips on lifestylechanges related to diet, physical activity, blood pressure,weight, cholesterol, blood sugar, sleep, and tobacco (Life’sEssential 8). There are also a few resources listed belowabout weight loss and safely getting back to a healthyweight in the postpartum period. [ACC’s Healthy Living](https://www.cardiosmart.org/topics/healthy-living) Miscellaneous visit resources Resources for clinic visits include tools for cliniciansproviding education to patients during the visit, as well asresources that patients can use to engage their providersin a discussion about their blood pressure management. The California Maternal Quality Care Collaborative’sHypertensive Disorders of Pregnancy Quality ImprovementToolkit includes several patient education checklists toassist clinicians in providing patients with educationabout hypertensive disorders of pregnancy, including adischarge education checklist and several checklists for thepostpartum period. The Preeclampsia Foundation provides a patientworksheet on making a plan for health beyond pregnancy.This worksheet allows patients to track information abouttheir pregnancy and delivery, blood pressure, weight andBMI, cholesterol, and A1c. The Centers for Disease Control and Prevention (CDC)has several handouts for patients to use during their visitto engage their clinicians with questions about managingtheir blood pressure. The handouts are available in bothEnglish and Spanish. Although these resources are notspecific to hypertensive disorders of pregnancy, thequestions and checklists are relevant for individuals withpostpartum hypertension. PART VI Postpartum Hypertension: Patient Education Resources ### Page 49 Social media and research engagement The Preeclampsia Foundation offers resources for individuals andfamilies to get involved, find support, and join research studiesabout preeclampsia. There are Facebook groups and other online communities forindividuals who have experienced preeclampsia and otherhypertensive disorders of pregnancy. (Posted links do not reflectaffiliation or endorsement) PART VI Postpartum Hypertension: Patient Education Resources ### Page 50 Part VII Appendices and References 1. Acknowledgements Funding: The development of this toolkit was supported by an AmericanCollege of Cardiology Chapter-Section Grant. Writers: Malamo Countouris, MD, MS (lead); Natalie Ann Bello, MD,MPH, FACC; Colleen Harrington, MD, FACC; Jennifer Lewey,MD, FACC; Kathryn Lindley, MD, FACC; Megan McLaughlin,MD, MPH; Kayle Shapero, MD, PhD Reviewers: Sri Adusumalli, MD, FACC; Alisse Hauspurg, MD, MS, FACC; AdiHirshberg, MD; Deirdre Mattina, MD, FACC; Michael Rakotz, MD,and AMA Team; Rachel Sinkey, MD; and Eugene Yang, MD, FACC ### Page 51 Tier I: Copper Intrauterine Device: The copper IUD is a smallnon-hormonal device in the shape of a “T” which isplaced inside the uterus to prevent pregnancy. It can stayin the uterus for up to 10 years and has a failure rate of0.8%. The major side effect related to the copper IUDis menstrual cramping, spotting and irregular bleedingwhich often improves over time. Etonogestrel subdermal Implant: This is a thin rodinserted under the skin in the upper arm. The rodreleases a hormone called progestin that is released overthe course of three years before it requires removal. Thetypical failure rate is 0.1%. The most common side effectis irregular bleeding, and less commonly, weight gainand acne. Levonorgestrel Intrauterine Device: This device isshaped like a ‘T” that is placed inside your uterus byyour doctor. It will release a small amount of a hormone,progestin, each day to significantly reduce the chance ofgetting pregnant. The device can stay in your uterus forup to 12 years, depending on the specific device. Thefailure rate is very low, typically 0.1-0.4%. Common sideeffects include irregular spotting and bleeding which willoften improve over time. While there is a risk of uterineperforation or IUD expulsion with IUD, these rates arevery low (perforation 0.1%, expulsion 3-11%). Sterilization: This is a permanent form of birth controlwhereby either a female undergoes a surgical procedure,most often a tubal ligation, or the male partner canundergo a vasectomy. This is associated with less than1% failure rate. This is considered a permanent form ofbirth control and is not intended to be reversible. Tier II: Combined Hormonal Contraceptive Pill: This pillcontains estrogen and progestin. The medication istaken at the same time every day to prevent pregnancy.The typical failure rate is 7%. Rare side effects includeblood clots, stroke, hypertension, and migraines.Estrogen-containing contraceptive devices can raiseblood pressure and thus are typically avoided in patientswith hypertensive disorders. Depot Medroxyprogesterone Injection: This is aninjection of a hormone called progestin which is givenevery three months. The typical failure rate is 4%.Common side effects include irregular bleeding or lightspotting and weight gain. Diaphragm/cervical cap: This is a type of barriermethod where a shallow cup is placed inside the vaginato block sperm. Diaphragms come in several differentsizes and a doctor should recommend the right size for aproper fit. The typical failure rate is 17%. PART VII 2. Contraception Appendix ### Page 52 Progestin Only Pill: This is a daily pill, similar to thecombined pill, but only contains a single hormone,progestin. It is often called the “mini-pill.” It can be anoption for women who cannot take estrogen. This treatmentrequires strict adherence and the pill must be taken at thesame time every day. The typical failure rate is 7%. Transdermal Patch: This is a small skin patch that can beworn on the abdomen, buttocks, or upper body. It releasesboth progestin and estrogen into the body. The patch isreplaced once a week for three weeks, and on the fourthweek no patch is applied in order to have a menstrual period.The typical failure rate is 7%. Common side effects includeheadaches, nausea, skin irritation or breast tenderness. Vaginal Ring: This is a flexible ring that is placed inside thevagina. The ring releases progestin and estrogen. At theend of three weeks, the ring is removed for the week youhave a period, and then the ring is replaced. The typicalfailure rate is 7%. Side effects may include headaches,nausea, vaginal discharge, or breast tenderness. Tier III: Fertility awareness method: Fertility pattern refers tothe number of days a month when you are most likelyto get pregnant. If you have a regular menstrual cyclethere are nine or more fertile days a month. The fertilityawareness method is understanding when these fertiledays occur and avoiding sexual intercourse on those days.It is important to remember that while getting pregnantoutside of this fertile window may be less likely, it is stillpossible. Failure rate is 2-23%. Spermicide: This a product that works by killing sperm toprevent pregnancy after sexual intercourse. Spermicidecomes in many different forms, as a foam, gel, cream,film, suppository, or tablet. They are inserted into thevagina prior to intercourse and left in place for 6-8hrs afterintercourse. Typical failure rate is 21%. Resources on contraception options: Lindley KJ, Bairey Merz CN, Davis MB, Madden T, Park K, BelloNA; American College of Cardiology Cardiovascular Diseasein Women Committee and the Cardio-Obstetrics Work Group.Contraception and Reproductive Planning for Women WithCardiovascular Disease: JACC Focus Seminar 5/5. J AmColl Cardiol. 2021 Apr 13;77(14):1823-1834. doi: 10.1016/j.jacc.2021.02.025. PMID: 33832608; PMCID: PMC8041063. [https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf](https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf) Cameron N, Blyler CA, Bello NA. Oral Contraceptive Pillsand Hypertension: A Review of Current Evidence andRecommendations. Hypertension. Online ahead of printFebruary 2023. [http://www.reproductiveaccess.org/wp-content/uploads/2014/06/2020-09-contra-choices.pdf](http://www.reproductiveaccess.org/wp-content/uploads/2014/06/2020-09-contra-choices.pdf) PART VII 2. Contraception Appendix ### Page 53 PART VII 3. Adverse Pregnancy Outcome Definition Appendix Hypertensive disorders of pregnancy and otheradverse pregnancy outcomes (APOs) increase the risk ofdeveloping cardiovascular risk factors and cardiovasculardisease. APOs such as preeclampsia are consideredcardiovascular risk enhancers in the updated 2018cholesterol guidelines, and an understanding of APOs caninform patient-physician discussions about cardiovascularrisk and lifestyle modifications. Therefore, it is critical forproviders in specialties such as cardiology, primary care,and family medicine to elicit a history of APOs from theirfemale patients. Below we list the definitions of key APOsthat have been shown to be associated with long-termcardiovascular risk. Adverse Pregnancy Outcomes Associatedwith Cardiovascular Disease: Preeclampsia: Blood pressure elevation ≥140/90mmHg after 20 weeks gestation, measured four hoursapart on two occasions, and new onset proteinuria(defined as 0.3 g or more of protein in a 24 hr urinecollection, single voided urine protein/creatinine ratio≥ 0.3, or dipstick reading of 2+) OR, in the absence ofproteinuria, new onset hypertension with new onsetof any of the following: thrombocytopenia (platelets< 100x109/L), renal insufficiency (serum creatinine>1.1mg/dl or doubling of serum creatinine), impairedliver enzymes (transaminases elevated to twice thenormal concentration), pulmonary edema, or neurologicsymptoms (including new onset headache unresponsiveto medications or visual symptoms). Severe preeclampsia: Preeclampsia as above, alongwith any of the following: severe hypertension (bloodpressure elevation ≥160/110 mmHg on two occasionsat least four hours apart after 20 weeks gestation),thrombocytopenia (platelets < 100x109/L), renalinsufficiency (serum creatinine >1.1mg/dl or doubling ofserum creatinine), impaired liver enzymes (transaminaseselevated to twice the normal concentration) or severepersistent right upper quadrant pain, pulmonary edema,or neurologic symptoms including new onset headacheunresponsive to medications or visual symptoms). HELLP syndrome: Hemolysis, elevated liver enzymes,thrombocytopenia (<100/109/L), with or withouthigh blood pressure, considered a variant of severepreeclampsia. Eclampsia: New onset seizures in a patient meetingpreeclampsia diagnosis as above. Gestational hypertension: Blood pressure elevation≥140 mmHg systolic or 90 mmHg diastolic after 20weeks gestation measured on two separate occasionsat least four hours apart when pre-pregnancy bloodpressure was normal. ### Page 54 Gestational diabetes: Glucose intolerance of variabledegree with the onset or first recognition duringpregnancy. Typically, a screening oral glucose tolerancetest is performed between 24-28 weeks of gestation andan abnormal response is defined as a fasting glucose>92mg/dl, followed by 1 hour post 75g oral glucose load>180mg/dl, or 2hr post 75g oral glucose load >153mg/dl. Preterm birth: Delivery before 37 weeks gestation Low birth weight: Weight at birth of less than 2500 g(5 lb 8 oz) Small for gestational age: Neonate weight below the10th percentile for the gestational age Large for gestational age: Neonate whose weight isabove the 90th percentile for the gestational age Fetal growth restriction (formerly intrauterine growthrestriction): Fetus whose estimated weight is less thanthe 10th percentile for gestational age Stillbirth/Intrauterine fetal demise: Fetal demise afterthe 20th week of gestation Miscarriage/spontaneous abortion: Spontaneouspregnancy loss before 20 weeks of gestation Placental abruption: Premature separation of theplacenta from the uterus before delivery Additional Adverse Pregnancy Outcomes: Macrosomia: A larger than average newborn, weighingmore than 4000 g (8 lb 13 oz) regardless of gestational age Postpartum hemorrhage: Cumulative blood lossof greater than or equal to 1,000 mL or blood lossaccompanied by signs or symptoms of hypovolemiawithin 24 hours after the birth process Premature rupture of membranes (PROM): Rupture ofthe amniotic sac prior to the onset of labor Preterm premature rupture of membranes (PPROM):Rupture of the amniotic sac prior to the 37th week ofpregnancy Uterine rupture: Spontaneous, complete division of allthree layers of the uterus. Associated with high rates offetal and maternal morbidity. Puerperal sepsis: Infection of the genital tract occurringat any time between the onset of the rupture ofmembranes or labor and the 42nd day postpartum Oligohydramnios: Disorder of amniotic fluid resulting indecreased amniotic fluid for gestational age Polyhydramnios: Excessive amniotic fluid in the uterusduring pregnancy Early neonatal death: Neonatal death occurring duringthe first 7 days of life PART VII 3. Adverse Pregnancy Outcome Definition Appendix ### Page 55 Sources: Parikh N, Gonzalez JM, Anderson CAM, et al. AdversePregnancy Outcomes and Cardiovascular DiseaseRisk: Unique Opportunities for CardiovascularDisease Prevention in Women: A Scientific StatementFrom the American Heart Association. Circulation2021;143(18):e902-e916. Lane-Cordova AD, Khan SS, Grobman WA, et al. Long-TermCardiovascular Risks Associated With Adverse PregnancyOutcomes: JACC Review Topic of the Week. JACC 2019;73(16):2106-2116. ACOG Practice Bulletin Number 222, Published December2018. https://www.preeclampsia.org/frontend/assets/img/advocacy_resource/Gestational_Hypertension_and_Preeclampsia_ACOG_Practice_Bulletin,_Number_222_1605448006.pdf PART VII 3. Adverse Pregnancy Outcome Definition Appendix ### Page 56 1. Mozaffarian D, Benjamin EJ, Go AS, et al. HeartDisease and Stroke Statistics—2015 Update.Circulation. 2015;131(4):e29-e322. doi:10.1161/CIR.0000000000000152. 2. Arora S, Stouffer GA, Kucharska-Newton AM, et al.Twenty Year Trends and Sex Differences in YoungAdults Hospitalized With Acute Myocardial Infarction.Circulation. 2019;139(8):1047-1056. doi:10.1161/CIRCULATIONAHA.118.037137. 3. Wu P, Haththotuwa R, Kwok CS, et al. Preeclampsiaand future cardiovascular health. Circ CardiovascQual Outcomes. 2017;10(2). doi:10.1161/CIRCOUTCOMES.116.003497. 4. Bellamy L, Casas J-P, Hingorani AD, Williams DJ. 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Informed consent--recall of riskinformation following epidural analgesia in labour. AnaesthIntensive Care. 1994;22(2):139-141. http://www.ncbi.nlm.nih.gov/pubmed/8210014. Accessed November 1, 2018. 10. Spaan J, Peeters L, Spaanderman M, Brown M.Cardiovascular Risk Management After a HypertensiveDisorder of Pregnancy. Hypertension. 2012;60(6):1368-1373. doi:10.1161/HYPERTENSIONAHA.112.198812. 11. Seely EW, Rich-Edwards J, Lui J, et al. Risk of futurecardiovascular disease in women with prior preeclampsia:a focus group study. BMC Pregnancy Childbirth.2013;13(1):240. doi:10.1186/1471-2393-13-240. 12. Benschop L, Duvekot JJ, Versmissen J, van BroekhovenV, Steegers EAP, Roeters van Lennep JE. Blood PressureProfile 1 Year After Severe Preeclampsia. Hypertension.2018;71(3):HYPERTENSIONAHA.117.10338.doi:10.1161/HYPERTENSIONAHA.117.10338. PART VII 4. References ### Page 57 13. Hauspurg A, Countouris ME, Jeyabalan A, et al. Riskof hypertension and abnormal biomarkers in the firstyear postpartum associated with hypertensive disordersof pregnancy among overweight and obese women.Pregnancy Hypertens. 2019;15:1-6. doi:10.1016/j.preghy.2018.10.009. 14. Hauspurg A, Lemon L, Cabrera C, Javaid A,Binstock A, Quinn B, Larkin J, Watson AR, BeigiRH, Simhan H. Racial Differences in PostpartumBlood Pressure Trajectories Among Women After aHypertensive Disorder of Pregnancy. JAMA NetwOpen. 2020 Dec 1;3(12):e2030815. doi: 10.1001/jamanetworkopen.2020.30815. PMID: 33351087;PMCID: PMC7756239. 15. Countouris M, Jaramillo Restrepo V, Bidani S, Catov J,Berlacher K, Jeyabalan A, Hauspurg A. Feasibility ofUtilizing Telehealth in a Multidisciplinary PostpartumHypertension Clinic. Womens Health Rep (NewRochelle). 2022 Nov 1;3(1):877-886. doi: 10.1089/whr.2022.0066. PMID: 36479373; PMCID: PMC9712043. 16. Hirshberg, Adi MD; Zhu, Yifan PhD; Smith-McLallen,Aaron PhD; Srinivas, Sindhu K. MD, MSCE. Associationof a Remote Blood Pressure Monitoring ProgramWith Postpartum Adverse Outcomes. Obstetrics &Gynecology 141(6):p 1163-1170, June 2023. | DOI:10.1097/AOG.0000000000005197 17. M, Packard E, Sperling S, Eberly LA, Ambrose M, JulienHM, Hirshberg A, Adusumalli S, Lewey J. Telemedicinemay increase visit completion rates in postpartumpatients with preeclampsia. PLoS One. 2022 Oct21;17(10):e0275741. doi: 10.1371/journal.pone.0275741.PMID: 36269782; PMCID: PMC9586337. 18. Kitt J, Fox R, Frost A, et al. Long-Term Blood PressureControl After Hypertensive Pregnancy FollowingPhysician-Optimized Self-Management: The POP-HTRandomized Clinical Trial. JAMA. 2023;330(20):1991–1999. doi:10.1001/jama.2023.21523 PART VII 4. References ### Page 58