Title: A prospective cohort study, understanding blood pressure changes in the immediate twelve weeks postpartum for women who had a hypertensive disorder in pregnancy and how existing care pathways identify and monitor women at risk of cardiovascular disease.
Funder: Health Education England

Abstract: Background Hypertensive disorders occur in approximately 10% of pregnancies. Evidence suggests that women who have hypertension in pregnancy are much more likely to develop cardiovascular disease (CVD). Women with a hypertensive disorder of pregnancy (HDP) are twice more at risk of heart disease and stroke, and four times more likely to develop hypertension after birth. Two out of three women who had hypertension in pregnancy will die from CVD (Pre-eclampsia Foundation, 2020) Recent evidence shows that young women are developing signs of CVD immediately in the postpartum period after HDP, rather than several decades later as previously presumed (Cain et al, 2016). Healthcare professionals (HCPs) are therefore presented with a unique opportunity to influence women around their future lifestyles to help combat against CVD. Hypothesis Hypertension is evident in a high proportion of women who had new onset of hypertension in pregnancy and much earlier in the postpartum period than previously assumed. Aim To observe the recovery of maternal blood pressure (BP) after a pregnancy with new onset hypertension after twenty weeks gestation and to explore how postpartum care might be improved. Objectives To observe the time course of recovery of maternal BP To measure the prevalence of persistent hypertension To assess the accuracy and acceptance of Home Blood Pressure Monitoring (HBPM) versus Ambulatory Blood Pressure Monitoring (ABPM) in the postpartum period To explore HCPs' knowledge and awareness of postpartum CVD risks and appropriate prevention strategiesMethods This will be a prospective cohort study design. Participants with new onset of hypertension during pregnancy will be asked to complete three days of HBPM every fortnight for twelve weeks with a twenty-four hour ABPM assessment at twelve weeks postpartum. Women will be asked to self report following their GP appointment at eight weeks postpartum, to assess whether their BP was measured and what lifestyle advice they were given to reduce the risk of CVD. Midwives and GPs will be asked to complete a cross sectional questionnaire after twelve months of primary data collection assessing their knowledge and awareness of HDP. Outcomes Key time points when BP should be monitored after birth Confirmation of the most suitable approach to BP monitoring? (ABPM or HBPM) Identification of women who would benefit from closer BP monitoring Gaps in knowledge about HDP and risk of CVD amongst HCPsAnticipated Impact and Dissemination This research aims to highlight gaps in the current provision of postnatal care for women who had HDP. Data from this study will inform the improvement of care for women who had HDP to reduce the risks of CVD. The results of this study will be distributed via peer reviewed academic journals, educational maternity update events for GPs and midwives and presenting at conferences and Action on Pre-eclampsia (APEC) expert meetings. Disseminating the results is anticipated to engage key stakeholders to spread the message and increase awareness of the prevalence of postnatal hypertension after HDP and what role HCPs play in the monitoring of hypertension and prevention of CVD.

Lay abstract: Hypertensive or blood pressure disorders occur in approximately 10% of pregnancies. The most serious of these is pre-eclampsia which affects 3-5% of pregnancies worldwide. Pre-eclampsia is a health condition that develops in pregnancy and attacks major organs which can be life threatening to mother and baby. Other blood pressure disorders include pregnancy induced hypertension and pre-existing high blood pressure before pregnancy. Women who experience blood pressure problems in pregnancy are at higher risk of developing heart disease, high blood pressure or having a stroke in later life than women who did not have blood pressure problems. These medical complications are commonly known as cardiovascular or heart disease. Research indicates that women who had blood pressure disorders in pregnancy are more likely to die from heart disease in later life. The more severe or earlier the blood pressure disorder arises in pregnancy, the higher the risk of future health problems for women. Although identifying and monitoring pregnant women with blood pressure disorders is very efficient, there are minimal efforts to monitor women at risk of health problems after pregnancy. During pregnancy, women have frequent blood pressure checks at their midwife and general practitioner (GP) appointments. Post birth, blood pressure and health checks are significantly reduced and it is up to the individual to seek a GP review. After discussing with three women who have experienced pre-eclampsia they reported that, as new mothers they are often exhausted and busy caring for their newborn that the responsibility to see their GP can be easily forgotten. Similarly, GPs have responsibility for a large number of patients, that often these check-ups may be missed or not a priority. Blood pressure disorders in pregnancy should prompt at least annual check-ups with the GP to monitor blood pressure, cholesterol levels and their body mass index. It is vital that women and GPs are educated about the importance of these check-ups and future health risks. The women involved in the development of this study reported that they were not aware of the risks to their future health until learning about this study. This research aims to investigate how women's blood pressure responds after birth and assess the time it takes to return to normal ranges. This will be calculated by participants undertaking three consecutive days of home blood pressure monitoring, every fortnight from birth until twelve weeks postpartum. At twelve weeks postpartum, women will have a twenty-four ambulatory blood pressure assessment. This will highlight the prevalence of persistent high blood pressure and how often GPs will need to monitor women's blood pressure in the immediate few weeks after birth. The research will explore the knowledge and awareness of healthcare professionals around blood pressure problems in pregnancy and future risk of cardiovascular disease through questionnaires. Women will be asked to complete a questionnaire after their six to eight week GP appointment, assessing if women recall having their blood pressure checked and/or the risks of heart disease explained to them and if they received any lifestyle advice to reduce these risks. Women will be asked to complete a second questionnaire at twelve weeks postpartum assessing their acceptance and preference of home and twenty four hour blood pressure monitoring. This research aims to identify any gaps in the current care of women in the postnatal period and use this information to provide better quality of care to women so they can lead healthier lives and reduce their risk of heart disease.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: CARDIOVASCULAR;REPRODUCTIVE HEALTH AND CHILDBIRTH