From the Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Dr. Hirshberg, Dr. Srinivas); Hospital of the University of Pennsylvania, Department of Nursing, Department of Obstetrics and Gynecology, Philadelphia, PA (Ms. Bittle); Penn Medicine Center for Health Care Innovation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Mr. Vandertuyn, Ms. Mahraj, Dr. Asch, Mr. Rosin); and the Department of Family Medicine, University of Washington, Seattle, WA (Dr. Bennett).
Abstract
- Objective: To investigate engagement with a bidirectional text messaging system as an alternative to in-person follow-up for postpartum women with hypertensive disorders.
- Methods: We utilized rapid-cycle innovation processes to implement postpartum SMS text messaging follow-up in women with hypertensive disorders who delivered between September–December 2014. Patients were given electronic blood pressure cuffs and education before discharge. Standard texts reminded patients to send blood pressures daily on each of the 7 days post discharge. The study obstetrician sent text message responses based on a pre-specified management algorithm. Ability to meet ACOG guidelines was defined as receiving at least 1 reading on post-discharge days 1 or 2 and days 5, 6, or 7.
- Results: We enrolled 32 patients. Six (19%) returned for usual care office blood pressure checks. We received at least 1 blood pressure from 27 (84%) participants. Nearly 20 (65%) texted readings on 5 of the 7 days. 27 (84%) texted at least one reading on day 1 or 2, and 21 (66%) texted at least one pressure on day 5, 6, or 7 ( P = 0.001 vs. usual care). Two patients required medications and none were readmitted for hypertension. Patients reported preference for home testing and text messaging over return visits.
- Conclusion: Remote blood pressure monitoring via text messaging is a patient-centered method for postpartum hypertension surveillance. Further testing is needed prior to widespread adoption within the broader obstetric community.
Key words: postpartum hypertension, remote monitoring, text-based intervention.
Hypertensive disease is a leading cause of maternal morbidity and mortality [1,2] and the leading cause of obstetric readmissions, accounting for 27% of obstetric readmissions in the United States in 2009 [3]. The majority of patients readmitted with hypertension have a diagnosis of hypertensive disorder of pregnancy on initial admission for delivery, indicating that these readmissions are the result of disease persistence or progression in contrast to new-onset disease. Peak blood pressure in these patients usually occurs 3 to 6 days postpartum [4–6] and is typically unaccompanied by warning symptoms. For these reasons, identifying patients who are at risk for persistent disease and being proactive in their postpartum care may decrease postpartum stroke and seizure. The recent Hypertension in Pregnancy guidelines provided by the American College of Obstetricians and Gynecologists (ACOG) recommend monitoring blood pressure for at least 72 hours postpartum (inpatient or outpatient) and again 7 to 10 days after delivery in women in whom a hypertensive disease of pregnancy is diagnosed [6].
Although there is a clear need for effective and reliable blood pressure surveillance for high-risk women soon after delivery, significant obstacles exist. Our own high-risk blood pressure transition clinic, which occurred every other week and was staffed by maternal-fetal medicine specialists, had an average attendance of only 30% over a 2-year period. Moreover, all of the hypertension-related readmissions occurred in the first 7 days post discharge, which was before the scheduled clinic visit for approximately 50% of patients. Phone call reminders were also found to be an ineffective strategy, as the women did not answer or return voice messages left by the practice. In fact, a postpartum unit quality improvement project validated that follow-up phone calls after discharge from the postpartum unit were less effective than text messaging when reminding women of their blood pressure follow-up appointment at the clinic [7].