The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care

Current Cardiovascular Risk Reports https://doi.org/10.1007/s12170-022-00706-x WOMEN AND HEART DISEASE (M. GOLD, SECTION EDITOR) The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care Eunjung Choi1 · Brigitte Kazzi2 · Bhavya Varma2 · Alexandra R. Ortengren3 · Anum S. Minhas1 · Arthur Jason Vaught4 · Wendy L. Bennett5 · Jennifer Lewey6 · Erin D. Michos1,7 Accepted: 25 August 2022 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022 Abstract Purpose of Review The “fourth trimester” concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women’s cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester. Recent Findings A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness. Summary Development of a comprehensive postpartum care plan with careful consideration of each patient’s risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve longterm cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery. Keywords Fourth trimester · Adverse pregnancy outcomes · Cardiovascular disease · Prevention · Blood pressure control · Weight management This article is part of the Topical Collection on Women and Heart Disease * Erin D. Michos 1 Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA 2 Department of Medicine, Johns Hopkins University School of Medicine, MD 21287 Baltimore, USA 3 Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, NH, Lebanon, USA 4 Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA 5 Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA 6 Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA 7 Division of Cardiology, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524‑B, Baltimore, MD 21287, USA 13 Vol.:(0123456789) Current Cardiovascular Risk Reports Introduction The fourth trimester concept, defined as the first 12 weeks after delivery (and beyond), has been proposed as a critical window of time for clinicians to intervene to optimize women’s cardiovascular health after pregnancy. Cardiovascular disease (CVD) remains a leading cause of maternal death in the USA. The number of maternal deaths has been increasing in the USA and approximately half of pregnancy-related deaths are due to cardiomyopathy, thrombotic pulmonary or other embolism, cerebrovascular accidents (CVA), hypertensive disorders of pregnancy (HDP), and other cardiovascular complications [1, 2]. Data from the Centers for Disease Control have shown that 18% of maternal deaths occur between 1 and 6 days postpartum, 21% between 7 and 41 days postpartum, and 13% after 42 days [3]. The American College of Obstetricians and Gynecologists (ACOG) recommends an initial postpartum evaluation within the first 3 weeks after delivery and a complete biopsychosocial evaluation within the first 3 months to optimize interconception and long-term health [4]. It is important for primary care clinicians, obstetricians, and cardiologists to have a systematic approach to comprehensive cardiovascular evaluation during this transition period. Postpartum visit attendance rates are low in general due to new mothers’ competing priorities, but particularly for those with low-income [5]. Racial disparities are also apparent in the care of postpartum women. Black, indigenous, and other women of color have the highest risk of pregnancy-related mortality and morbidity and they also have higher risk of getting fragmented postpartum medical care [6,7,8••] There is an urgent need to direct attention to Fig. 1  Snapshot of notable postpartum risk factors, multidisciplinary team members, and supplemental non-clinic interventions to be considered in postpartum cardiovascular care these women who will benefit most from carefully coordinated transition of care after delivery. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women in order to [1] follow up pre-existing medical conditions, [2] evaluate symptoms and signs for common postpartum complications, and [3] identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as HDP, gestational diabetes mellitus (GDM), postpartum weight retention, postpartum depression, and lactation. Additionally, we will review different outpatient interventions used for improvement of transitions in cardiovascular care during the fourth trimester (Fig. 1). We refer to “women” throughout this review based on presumed female sex assigned at birth, as the majority of prior studies focused on “women” and did not define how gender was ascertained or assess other gender identities. However, we acknowledge that not all birthing persons self-identify as women. Unfortunately, insufficient evidence exists regarding maternal outcomes for individuals who are transgender, non-binary, or other, which is an area of needed research. Addressing Maternal Cardiovascular Risk Profile in the Fourth Trimester Hypertensive Disorders of Pregnancy Hypertensive disorders of pregnancy (HDP) complicate up to 20% of all pregnancies and include preeclampsia, eclampsia, chronic hypertension of any etiology, and preeclampsia Th (...truncated)