AURORA, COLO. – Imagine that you are covering for a colleague over the weekend, and you get call from a patient.
The patient is a 36-year-old woman who is 3 days postpartum after a spontaneous vaginal delivery. She has a headache and just arrived home after hospital discharge. She’s calling because after using the blood pressure cuff that the hospital sent her home with, her reading is > 150/90 mm Hg, indicating that she is hypertensive.
You try to pull up her records but realize her delivery hospital isn’t part of your system’s electronic health record. What do you do?
This scenario was presented at a session of the annual meeting of the Society of General Internal Medicine during a panel focused on providing care in the fourth trimester as patients transition between ob.gyn. care and primary care.
“If you send her to the emergency room, she might get sent home,” said Chloe A. Zera, MD, MPH, a maternal-fetal medicine specialist at Beth Israel Deaconess Medical Center, Boston. “I would strongly recommend you figure out where she delivered and tell her to go back there because she will almost certainly get readmitted for blood pressure control.”
When stepping in to treat someone who recently gave birth, Dr. Zera said that clinicians have to be mindful that though many of the deaths of mothers and infants occur on the day of birth, a substantial proportion occur within the first 6-7 weeks postpartum. Clinicians must be aware of possible complications and ask probing questions if they don’t have a patient’s medical records at hand.
“Maternal mortality is a crisis in the United States, which is probably reflective of the sort of social and political realities we’re living in right now,” said Dr. Zera, associate professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, Boston. “About 700 women die each year in the U.S. from a pregnancy or its complications.”
Dr. Zera recommended that clinicians ask about patients’ birth stories specifically, at how many weeks they gave birth, what kind of delivery they had, and whether they were they induced for any reason.
“Everybody’s birth story is really important in their lives, people know the details and want to talk about their birth stories,” she said.
Starting point
Clinicians should start out by asking questions regarding how the patient delivered but also how much the baby weighed at birth.
“Both really small and really large babies are associated with later maternal complications,” Dr. Zera said. “For example, an 8-pound baby at 34 weeks is off the charts while at 42 weeks, that’s totally normal.”
Clinicians should also ask about complications prior to the birth, which might include questions regarding high blood pressure, blood sugar concerns, hospitalizations before birth, length of stay for the birth, and whether the infant had a neonatal intensive care stay.
Any of these factors can weigh into adverse pregnancy outcomes. Experiencing a hypertensive pregnancy, for example, can put patients at a higher risk for cardiovascular events, and up to 10% of all pregnancies are complicated by hypertensive disorders.
Women who experience preeclampsia have two to four times the risk for coronary heart disease.
Hypertensive pregnancies can also result in patients developing posttraumatic stress disorder, anxiety, and even producing less milk, according to Ann C. Celi, MD, MPH, an internal medicine specialist at Brigham and Women’s Hospital.