Hypertensive Disorders in Pregnancy

Transcription

The Maternal Health Clinic
Who and How?
Graeme N. Smith
MD, PhD, FRCSC
www.themothersprogram.ca
gns@queensu.ca
Kingston General Hospital
Queen’s University
• No conflict of interest to declare except for
holding peer-reviewed grant funding
related to this presentation.
Objectives
• Be able to list the pregnancy-related
cardiovascular risk indicators
• Be able to develop an action plan for a
patient with one of the pregnancy-related
cardiovascular risk indicators
Pre-eclampsia and risk of future
Cardiovascular Disease
•
•
•
•
Hypertension:
3.70 (2.70-5.05)
Ischaemic heart disease:
2.16 (1.86-2.52)
Major stroke:
1.81 (1.45-2.27)
Premature cardiovascular death:1.49 (1.05-2.14)
• premature CVD (severe PE + IUGR):
8.12 (4.31-15.33)
Metabolic Syndrome
Risk Factor
Scoring Cut Offs
Elevated Blood Pressure
≥ 130/85 mmHg
Abdominal Obesity
> 88 cm waist circumference*
Elevated Triglycerides
> 1.7 mmol/L
Decreased HDL
< 1.3 mmol/L
Elevated Fasting Glucose
> 5.6 mmol/L
Yes/No
The metabolic syndrome criteria are met if 3 or more of the
above risk factors are present.
Year 1
Year 3
Control (%)
6.8
6.4
PE (%)
18.2
21.2
Smith et al., J. Obstet Gynecol Canada 2012.
Global CVD Risk Estimation
Sex
Age
Smoking
BMI
Total Cholesterol
LDL Cholesterol
HDL Cholesterol
Fasting Glucose
Systolic Blood Pressure
10 Year Risk
30 Year Risk
Lifetime Risk
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Diastolic Blood Pressure
Antihypertensive Usage
X
X
X
X
C
C
0
-L
ar
ar
e
ife
tim
e
tim
Ye
ar
Ye
Ye
ar
Ye
l-L
ife
-3
PE
on
tro
0
l-3
0
PE
on
tro
-1
l-1
0
PE
on
tro
k
is
k
is
R
R
k
is
k
is
R
R
k
is
k
is
R
R
)
=9
9
)
=1
18
)
=9
9
(n
(n
)
=1
18
)
(n
(n
=9
7
=1
18
)
(n
(n
c
b
a
10 and 30 Year Risk (Percent)
40
60
60
30
50
20
40
30
10
20
10
0
Percent at High Lifetime Risk
C
Global CVD Risk Estimation
100
0
Smith et al., J Obstet Gynecol Canada 2012.
Pregnancy is a Cardiovascular
Stress Test!
Pregnancy is a "stress test" that can reveal subclinical trajectories and identify new
opportunities for chronic disease prevention
Rich-Edwards, J. W. et al. Hypertension 2010;56:331-334
Copyright ©2010 American Heart Association
Pregnancy is a "stress test" that can reveal subclinical trajectories and identify new
opportunities for chronic disease prevention
Rich-Edwards, J. W. et al. Hypertension 2010;56:331-334
Copyright ©2010 American Heart Association
Pregnancy-Related CVR Indicators
• Pre-eclampsia, HELLP, Eclampsia
• Gestational Hypertension
• Gestational Diabetes
• Gestational Impaired Glucose Tolerance
• IUGR (<2500g at term, <5th %tile)
• Idiopathic preterm birth
• Placental abruption
Pregnancy as a Window to Future Health
The development of complications in pregnancy
provides a new window of opportunity for early heart
disease risk screening and intervention for women.
Graeme Smith and George Saade
SMFM 2013
The Maternal Health Clinic:
A New Window of Opportunity for Early
Heart Disease Risk Screening and
Intervention for Women with Pregnancy
Complications
Graeme N. Smith, MD, PhD, FRCSC, Jessica Pudwell, MPH, Michelle
Roddy, RN, BScN
Department of Obstetrics and Gynecology, Kingston General Hospital,
Queen’s University, Kingston ON
Smith et al. J Obstet Gynaecol Can 2013;35(9):831–839
BORN Ontario (2005-2009) (n=644,412)
Prevalence
Pregnancy-related CVR indicators (PE, GH,
GDM, IUGR, preterm birth, abruption)
20.58
Traditional CVRs (smoking, chronic HTN,
DM)
14.99
Patient Delivers
at KGH
Relevant Complications:
 Preeclampsia or HELLP Syndrome
 Gestational Hypertension
 Gestational Diabetes or Impaired Glucose Tolerance
 Intrauterine Growth Restriction or Term Baby <2500g
 Idiopathic Preterm delivery
 Clinically Significant Placental Abruption
Screened by
Medical Staff
If Patient has Developed One or
More Relevant Complications
Maternal Health
Clinic Referral
Form Completed
Top Portion
of Form
Sent to
Clinic Staff
Patient Counselled by Medical
Staff and Given Bottom Portion
of the Form
(Includes an Opt-Out Option)
Appointment
Package
Sent at 3
months
Postpartum
Confirmation
Call Placed 2
weeks after
Package
Sent
Reminder
Call Placed
the week
of the
Appointment
Maternal
Health
Clinic
Visit
Clinic
Appointment
6-8 Weeks after Appointment, If Blood
Work Results Not Already Received
1st Blood Work Reminder
Blood Work
Results Received
10-12 Weeks after Appointment, If Blood
Work Results Not Already Received
2nd Blood Work Reminder
Maternal Health Clinic
Follow Up Form Generated
18-20 Weeks after Appointment,
If Blood Work Results Not Already
Received
Final Blood Work Reminder
Letters Dictated to Patient
and Family Doctor
28 Weeks after Appointment,
If Blood Work Results Not Already Received
Chart Closed
Notification Sent to Patient
and Partial Records Sent to
Family Doctor
Follow Up Package Sent to
Family Doctor and Letter
Sent to Patient
If Applicable,
Additional Referral
Made to Specialty
Service
Cardiac
Rehab Program
Maternal Health
Clinic Analysis
Group
Women Invited
to Clinic Who Did
Not Attend
Preeclampsia, n (%)
27 (29.3)
29 (16.7)
Gestational Hypertension, n (%)
18 (19.6)
29 (16.7)
Gestational Diabetes or Impaired Glucose
Tolerance, n (%)
30 (32.7)
62 (36.0)
5 (5.4)
8 (4.7)
Preterm Birth, n (%)
27 (29.3)
52 (30.2)
IUGR, n (%)
14 (15.2)
26 (15.1)
Abruption, n (%)
Smith et al., Am J Obstet Gynecol 2013 (In press)
Total (n)
SBP (mmHg), mean (SD)
<120, n (%)
120-139, n (%)
140-159, n (%)
≥160 or Taking an Antihypertensive Medication, n (%)
DBP (mmHg), mean (SD)
<80, n (%)
80-89, n (%)
90-99, n (%)
≥100 or Taking an Antihypertensive Medication, n (%)
Using Antihypertensive Medication, n (%)
Total Cholesterol (mmol/L), mean (SD)
119.9 (13.77)
52 (56.5)
25 (27.2)
8 (8.7)
7 (7.6)
81.73 (10.90)
38 (41.3)
28 (30.4)
16 (17.4)
≤ 2.8, n (%)
> 2.8, n (%)
Fasting OGTT, mean (SD)
2 Hour OGTT, mean (SD)
Abnormal OGTT Results, n (%)
4.88 (0.44)
5.98 (1.39)
1 (3.3)
HDL Cholesterol (mmol/L), mean (SD)
≥ 1.3, n (%)
< 1.3, n (%)
LDL Cholesterol (mmol/L), mean (SD)
< 2.6, n (%)
≥ 2.6, n (%)
Triglycerides (mmol/L), mean (SD)
< 1.7, n (%)
≥ 1.7, n (%)
Glucose (mmol/L), mean (SD)
< 5.6, n (%)
≥ 5.6, n (%)
CRP (mg/L), mean (SD)
≤ 3.0, n (%)
> 3.0, n (%)
ALB-Cr Ratio (mg/mmol), mean (SD)
92
10 (10.9)
6 (6.5)
4.69 (0.96)
51 (55.4)
22 (23.9)
11 (12.0)
8 (8.7)
1.45 (0.33)
59 (64.1)
33 (35.9)
2.77 (0.81)
43 (46.7)
49 (53.3)
1.12 (0.92)
81 (88.0)
11 (12.0)
4.71 (0.39)
87 (97.8)
2 (2.2)
4.39 (4.61)
37 (50.7)
36 (49.3)
2.41 (4.22)
79 (86.8)
12 (13.2)
<4.65, n (%)
4.65-5.15, n (%)
5.16-6.19, n (%)
>6.20, n (%)
92
OGTT (mmol/L), n
92
92
92
92
92
89
73
91
62
91
30
29
29
30
[A]
Maternal Health
Clinic Analysis
Group
[B]
PE-NET Control
Group
[C]
PE-NET PreEclampsia Group
Comparis Comparis
on
on
[A] vs [B] [A] vs [C]
Test
Lifetime
CVD Risk
All Optimal (15, 16.3%)
One or More Not Optimal (31, 33.7%)
One or More Elevated (19, 20.7%)
1 Major (18, 19.5%)
2 or More Major (9, 9.8%)
1 Major (6, 5.1%)
2 or More Major (0, 0%)
1 Major (11, 11.1%)
2 or More Major (9, 9.1%)
p< 0.0001
NS
Multiple
Comparison
Chi Square
30 Year
CVD Risk*
(%)
Median = 7.5
(IQR = 5.9-12.0)
Median = 5.3
(IQR = 4.0-7.0)
Median = 7.0
(IQR = 5.0-9.8)
p< 0.0001
NS
MannWhitney U
Test
Metabolic
Syndrome
Criteria
Met
No (76, 82.6%)
Yes (16, 17.4%)
No (110, 93.2%)
Yes (8, 6.8%)
No (81, 81.8%)
Yes (18, 18.2%)
p <0.05
NS
Chi Square
Smith et al., Am J Obstet Gynecol 2013 (In press)
• Certain pregnancy complications are
reliable markers of underlying CVRs
• Early identification and treatment of
cardiovascular risk factors can prevent
long-term cardiovascular disease
The MotHERS Program
(www.themothersprogram.ca)
• Clinical Research Group
• Heather Ramshaw, HBSc
• Michelle Roddy, RN
• Jessica Pudwell, MPH
• Collaborators
• Queen’s University
• Chandra Tayade, PhD
• Anne Croy, DVM, PhD
• Sue MacDonald, MD,MSc
• Karen Weisbaum, LLD
• Raveen Pal, MD
• Damian Redfearn, MB
• U. of Toronto
• Michelle Hladunewich, MD
• Joel Ray, MD, MSc
• Ravi Retnakaran, MD, MSc
• Basic Science Research Group
•Carolina Venditti (PhD)
•Malia Murphy (PhD)
•Karalyn McRae (PhD)
•Victoria Sattarova (MSc)
• Richard Casselman
• Ottawa Maternal Neonatal Investigators
(OMNI)
• Mark Walker, MD, MSc
• Shi-Wu Wen, MB, PhD
• Kara Nerenberg, MD, MSc
www.themothersprogram.ca
HIP:
Health Improvement after
Pregnancy
Mobile Website-based physical activity and
diet program
To facilitate postpartum weight loss and
cardiovascular risk reduction through Lifestyle
modification

Hypertensive Disorders in Pregnancy

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