- Email: [email protected]
Cardiovascular Risk Reduction and Weight Management at a Hospital-Based Postpartum Preeclampsia Clinic
WOMEN’S HEALTH
Cardiovascular Risk Reduction and Weight Management at a Hospital-Based Postpartum Preeclampsia Clinic Rahim Janmohamed, MD,1 Erin Montgomery-Fajic, BASc,2 Winnie Sia, MD,1,3 Debbie Germaine, BScN, NP,4 Jodi Wilkie, BSc Pharm,4 Rshmi Khurana, MD,1,3 Kara A. Nerenberg, MD, MSc5 Department of Obstetrics and Gynecology, University of Alberta, Edmonton AB
1
Nutrition Services, Alberta Health Services, Edmonton AB
2
Department of Medicine, University of Alberta, Edmonton AB
3
Alberta Health Services, Edmonton AB
4
Ottawa Hospital Research Institute, University of Ottawa, Ottawa ON
5
Abstract
Résumé
Objective: Women who develop preeclampsia during pregnancy are at high risk of developing future chronic diseases, including premature cardiovascular disease. We have established an interdisciplinary clinic that aims to prevent cardiovascular disease through educational counselling focused on lifestyle modifications in the early postpartum period. The objective of this study was to evaluate changes in weight and cardiovascular risk factors in participating women after six months of attendance at the clinic.
Objectif : Les femmes qui en viennent à connaître une prééclampsie pendant la grossesse sont exposées à un risque élevé d’en venir par la suite à présenter des maladies chroniques, dont la maladie cardiovasculaire prématurée. Nous avons mis sur pied une clinique interdisciplinaire qui vise à prévenir la maladie cardiovasculaire par l’offre de services de counseling pédagogique axés sur les modifications à apporter au mode de vie aux débuts de la période postpartum. Cette étude avait pour objectif d’évaluer les modifications du poids et des facteurs de risque cardiovasculaire chez les participantes, après six mois de consultations à la clinique.
Methods: We conducted a retrospective chart review of women who had a pregnancy complicated by preeclampsia, and who subsequently attended the Postpartum Preeclampsia Clinic. Study subjects had baseline assessments of lifestyle, physical, and laboratory parameters. Individualized goals for cardiovascular risk reduction and lifestyle were established, centering on physical activity and dietary modifications. The primary outcome was change in weight. Results: Over the study period, 21 women were seen for a minimum of six months of follow-up. At an average (± SD) of 4.4 ± 1.4 months postpartum, subjects showed a non-significant improvement in weight (mean weight loss of 0.4 ± 4.5 kg) and BMI (mean decrease in BMI 0.1 ± 1.7 kg/m2). Physical activity improved significantly, from 14% of subjects participating in physical activity before pregnancy to 76% at a mean of 4.4 months postpartum. Conclusion: This study has demonstrated the early benefits of a longitudinal interdisciplinary intervention with counselling about lifestyle modifications for prevention of cardiovascular disease in women with recent preeclampsia. A study with a larger sample size and longer duration of follow-up is planned to confirm these findings.
Key Words: Preeclampsia, postpartum care, nutrition, vascular disease, health promotion and prevention, weight management Competing Interests: None declared. Received on September 9, 2014 Accepted on November 10, 2014
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Méthodes : Nous avons mené une analyse rétrospective des dossiers des femmes dont la grossesse avait été compliquée par la prééclampsie et qui avaient par la suite fréquenté la Postpartum Preeclampsia Clinic. Pour déterminer les paramètres de départ, les participantes à l’étude ont été soumises à des évaluations du mode de vie, à des examens physiques et à des analyses de laboratoire. Des objectifs personnalisés en matière de réduction du risque cardiovasculaire et de modification du mode de vie ont été établis, le tout étant axé sur l’activité physique et les modifications du régime alimentaire. La modification du poids constituait le critère d’évaluation principal. Résultats : Au cours de la période d’étude, 21 femmes ont fait l’objet d’un suivi d’une durée minimale de six mois. À 4,4 ± 1,4 mois postpartum en moyenne (± σ), les participantes présentaient une amélioration non significative en matière de poids (perte pondérale moyenne de 0,4 ± 4,5 kg) et d’IMC (diminution moyenne de l’IMC de 0,1 ± 1,7 kg/m2). Le niveau d’activité physique a connu une amélioration significative, passant de 14 % des participantes pratiquant des activités physiques avant la grossesse à 76 % après 4,4 mois postpartum en moyenne. Conclusion : Cette étude a démontré les avantages précoces d’une intervention interdisciplinaire longitudinale, s’accompagnant de services de counseling sur les modifications à apporter au mode de vie, pour assurer la prévention des maladies cardiovasculaires chez des femmes ayant récemment connu une prééclampsie.
Cardiovascular Risk Reduction and Weight Management at a Hospital-Based Postpartum Preeclampsia Clinic
Nous prévoyons mener une étude comptant un échantillon plus large et un suivi de plus longue durée, en vue de confirmer ces constatations. J Obstet Gynaecol Can 2015;37(4):330–337
INTRODUCTION
T
he occurrence of preeclampsia during pregnancy identifies a group of women who are at increased risk of developing future chronic diseases (e.g., metabolic syndrome, obesity, type 2 diabetes, chronic hypertension, kidney disease, and premature cardiovascular disease).1–8 Many of these chronic diseases may be largely prevented through implementation of simple postpartum lifestyle interventions.9,10 Accordingly, several Canadian and international organizations have recommended routine postpartum follow-up of women with PE to provide educational counselling regarding healthy lifestyle activities for chronic disease prevention.11–15 There are two components of these postpartum lifestyle recommendations. The first is loss of all gestational weight and achievement of a normal BMI of 18 to 24.9 kg/m2.13,14,16 The second is a set of specific lifestyle recommendations which mirror Health Canada’s minimum lifestyle recommendations for nutrition (7 to 8 servings of fruits and vegetables per day)17 and physical activity (150 minutes of moderate to vigorous physical activity per week).18 Despite these recommendations, observational data suggest that the majority of Canadian women are not meeting these basic health prevention guidelines.19,20 To date, few studies have assessed the long-term effectiveness of lifestyle interventions (either exercise or dietary modifications) for CVD prevention in postpartum women who had PE. Such women are among those at highest risk of developing premature CVD.14,21,22 This study examined the effects of longitudinal attendance at an interdisciplinary clinic providing lifestyle educational counselling in the early postpartum period on cardiovascular risk factors and weight management in Canadian women with recent PE. Specific study objectives were to assess changes in cardiovascular risk factors and ABBREVIATIONS CVD
cardiovascular disease
PE-NET Pre-Eclampsia New Emerging Team PE
preeclampsia
PPPEC The Postpartum Preeclampsia Clinic RAH
Royal Alexandra Hospital
SD
standard deviation
weight in subjects after six months of follow-up, and to examine changes in lifestyle behaviours in subjects from baseline to six months of follow-up. METHODS
The Postpartum Preeclampsia Clinic at the Royal Alexandra Hospital in Edmonton, Alberta, is an interdisciplinary clinic that was established in September 2010. PPPEC team members include an obstetric medicine physician (general internist), a nurse practitioner, a registered dietitian, and a pharmacist (online eAppendix 1). Medical trainees (clinical fellows and residents) and students of other health disciplines attend the clinic in rotation. Women with a recent diagnosis of PE are assessed and followed longitudinally in this clinic. The main goals of the PPPEC are: 1. to educate women about the future health implications of PE, focusing on the risk of PE in subsequent pregnancies and the risk of premature CVD; 2. to assess modifiable cardiovascular risk factors; and 3. to improve cardiovascular risk factors and achieve weight management primarily through counselling about lifestyle modifications (diet and exercise), with supplemental use of pharmacologic therapies when indicated. In general, women with PE are referred by their obstetrical care provider to the PPPEC at the time of discharge from hospital after delivery. At the first clinic visit, women view a 20-minute computerized presentation about preeclampsia and future heart health which introduces the importance of lifestyle modifications to reduce cardiovascular risk. They then complete a health profile (a two-page questionnaire) that provides the clinic team with information about the woman’s PE history, medical history (including standard cardiovascular risk factors), family history, medications, and social history (tobacco, alcohol, caffeine, recreational drugs, exercise, and stress). Exercise is recorded on the selfreported questionnaire as whether the woman participated in any form of regular exercise before pregnancy. The nurse practitioner or obstetric medicine specialist reviews this information and obtains any additional information directly from the patient or from the hospital chart. A standardized physical examination is performed, including measurement of height, weight, waist circumference, and blood pressure. Vascular risk is assessed at the baseline visit by examining glycemic status (hemoglobin A1C and fasting blood glucose level or a 75 gram oral glucose tolerance test) and serum lipid levels. These investigations are repeated after six months if indicated. Resolution of preeclampsia is confirmed at the baseline visit by performing a CBC APRIL JOGC AVRIL 2015 l 331
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PPEC flow diagram PPEC patients scheduled September 3, 2010, to March 18, 2013 104 patients scheduled for initial consult cococonsultconsult 104 patients scheduled for initial consult
78 patients attended initial consult
26 patients did not attend initial consult (no shows)
38 patients did not return for a follow-up appointment
40 patients returned for follow-up appointments 19 patients had less than 6 months of clinic follow-up 21 patients had 6 months or more of clinic followup and were included in the study
and measuring serum creatinine, serum AST, serum ALT, and spot urine protein to creatinine ratio. All other investigations (e.g., ECG or echocardiogram) are ordered on an individual basis. At the initial visit, women meet individually with the team members. The dietitian assesses each woman’s diet and provides counselling at the initial visit and as needed at follow-up visits. Women are educated in reading food labels, and in the optimal dietary intake of fat, sodium, and fibre. Simple nutritional goals are established through individualized discussions with each woman; these goals generally are to achieve a modest weight reduction of one half to one pound per week. The clinic pharmacist educates patients about new medications and counsels women about smoking cessation. The pharmacist also monitors and adjusts medications for hypertension, hyperlipidemia, diabetes, and smoking cessation as appropriate. The obstetric medicine specialist or nurse practitioner assesses each woman for other medical issues. All team members counsel women about the importance of regular physical activity and offer suggestions on integration of physical activity into daily life. Frequency, duration, and type of physical activities are listed as goals and are recorded in the follow-up visits. Finally, the team formulates an integrated management plan individualized for each woman. At the end of each clinic visit, participants are given a paper copy of the PPPEC Action Plan (online eAppendix 2). In this document, women set individualized goals for each of the 332 l APRIL JOGC AVRIL 2015
following: blood pressure, serum lipid levels, blood glucose level, tobacco use, dietary changes, physical activity, and weight loss. These goals are reviewed and updated at each visit. Information regarding each woman’s clinical status and goals are summarized in a letter and sent to her family physician. Participants are generally seen in the clinic for follow-up every three to six months for the first year postpartum. We included in this chart review all women attending the PPPEC who met the following eligibility criteria: 1. were aged 18 years or older; 2. attended the PPPEC for a minimum of six months during the study period (September 3, 2010, to March 18, 2013); and 3. had a confirmed diagnosis of PE, eclampsia or HELLP (hemolysis, elevated liver enzymes, or low platelets) syndrome (using the Society of Obstetricians and Gynaecologists of Canada 2008 Guidelines definitions23) in the most recent pregnancy. A standardized electronic method for data extraction using REDCap data management system24 was developed and tested for inter-rater reliability. The following data were collected from the hospital and PPPEC charts: patient demographics, clinical measurements, obstetrical history, results of investigations, and treatment goals for the baseline visit and all follow-up visits up to six months.
Cardiovascular Risk Reduction and Weight Management at a Hospital-Based Postpartum Preeclampsia Clinic
Baseline participant characteristics are presented as means with standard deviations or as medians with interquartile range for continuous variables, and as counts with percentages for categorical variables. Comparisons between groups were made using the Student t test and Kruskal-Wallis test for continuous variables and chisquare tests for categorical variables. Statistical significance was predetermined at a P value of < 0.05. All statistical analyses were performed using SAS software, version 9.3 (SAS Institute Inc., Cary, NC). This study was approved by the Research Ethics Board at the University of Alberta. RESULTS
As outlined in the Figure, 78 women were seen at least once in the PPPEC during the study period. Of these, 21 women were seen for a minimum of six months of followup and met the eligibility criteria. The initial clinic visit was at a mean (± SD) of 1.8 ± 3.0 months postpartum. The visit closest to the six-month follow-up period occurred at a mean of 4.4 ± 1.8 months postpartum. The main characteristics of the PPPEC cohort are summarized in Table 1. Women seen in the PPPEC were an average of 29.1 ± 3.6 years old (SD), 66.7% were primigravid, and 85.7% had singleton pregnancies. Overall, PE was detected before 34 weeks in 66.7% of women, and the mean gestational age at delivery of the entire cohort was 31.8 ± 4.0 weeks. In addition, two thirds of women required Caesarean section for delivery. Similarly, two thirds of women received magnesium sulfate for eclampsia prevention, but one woman (4.8%) had developed eclampsia. Before pregnancy, the mean self-reported weight of the PPPEC cohort was 81.3 ± 25.0 kg, and mean BMI was 31.1 ± 10.2 kg/m2. At the first postpartum visit (at a mean 1.8 months postpartum), the mean weight in the cohort was 85.7 ± 24.4 kg and mean BMI was 32.7 ± 9.8 kg/m2. After an average of 4.4 ± 1.4 months postpartum, there was a non-significant mean weight loss of 0.4 ± 4.5 kg and mean decrease in BMI of 0.1 ± 1.7 kg/m2 (Table 2). Before pregnancy, four of 21 women (19%) had a history of chronic hypertension, one woman (4.8%) smoked, and one woman (4.8%) had a family history of cardiovascular disease. None in the cohort had pre-pregnancy dyslipidemia, pre-pregnancy type 1 or 2 diabetes, or gestational diabetes. At the first postpartum clinic visit, the mean blood pressures recorded were 123.0 ± 12.1 mmHg systolic and 81.3 ± 9.6 mmHg diastolic; 43% of women were taking antihypertensive medication. At a mean of 4.4 months postpartum, there was a non-significant reduction
Table 1. Participant characteristics at baseline assessment Overall cohort (N = 21)
Participant characteristic Demographics Mean age, years (SD)
29.1 (3.6)
Married or common-law, n (%)
16 (76.2)
Obstetrical history Primigravid, n (%)
14 (66.7)
Prior history of preeclampsia, n (%)
1 (4.8)
Delivery history Mean gestational age at delivery, weeks (SD)
31.8 (4.0)
Caesarean section, n (%)
14 (66.7)
Baby currently in NICU, n (%)
12 (57.7)
Cardiovascular risk factors Chronic hypertension, n (%)
4 (19.0)
Dyslipidemia, n (%)
0
Pre-pregnancy DM or GDM, n (%)
0
Current smoker, n (%)
1 (4.8)
Family history of CVD, n (%)
8 (38.1)
DM: diabetes mellitus (type 1 or 2); GDM: gestational diabetes mellitus
in mean blood pressures; however, only four women (19%) were still taking any antihypertensive medication. Too few women had data available on fasting lipid and glucose levels at both baseline and follow-up assessments to assess changes accurately. Fourteen percent of women (3/21) reported participating in any regular physical activity prior to pregnancy and 19% (4/21) reported participating in any regular physical activity during pregnancy. This increased to 33% (7/21) at the first clinic visit, and to 76.2% (16/21) at a mean of 4.4 months postpartum (P < 0.05) (Table 2). There were no significant changes in the proportion of women who achieved a balanced diet between baseline (14.3%) and 4.4 months postpartum (14.3%). Fewer women breastfed at the 4.4 month follow up compared to the initial visit (23.8% vs. 47.6%, not significant). DISCUSSION
This study has demonstrated the effectiveness of longitudinal counselling by an interdisciplinary team about lifestyle modifications in the early postpartum period in women with recent PE as an opportunity for CVD prevention. Our longitudinal approach to vascular risk reduction is slightly different from the approach in the Kingston Maternal Health Clinic, in which women with pregnancy complications (e.g., PE, gestational diabetes, preterm birth) are seen for cardiovascular risk assessment APRIL JOGC AVRIL 2015 l 333
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Table 2. Changes in clinical measures over time Pre-pregnancy
Baseline visit
Visit closest to 6 months of follow-up
—
1.8 (3.0)
4.4 (1.4)
Mean weight, kg (SD)
81.3 (25.0)
85.7 (24.4)
84.7 (24.0)
NS
Mean BMI, kg/m2 (SD)
31.1 (10.2)
32.7 (9.8)
32.3 (9.5)
NS
—
101.6 (16.2)
102.7 (21.9)
NS
Systolic BP, mmHg
—
123.0 (12.1)
119.1 (8.9)
NS
Diastolic BP, mmHg
—
81.3 (9.6)
79.3 (7.9)
NS
Total cholesterol, mmol/L
—
5.1 (1.1) n=9
4.8 (1.1) n = 11
NS
LDL-cholesterol, mmol/L
—
2.9 (0.7) n=9
2.7 (0.6) n = 12
NS
HDL-cholesterol, mmol/L
—
1.6 (0.2) n=8
1.3 (0.3) n = 12
NS
Triglycerides, mmol/L
—
1.8 (1.3) n=9
1.9 (1.1) n = 11
NS
Total cholesterol/HDL-cholesterol, ratio
—
3.3 (0.9) n=9
4.0 (0.9) n = 11
NS
Fasting glucose, mmol/L
—
4.9 (0.5) n=7
5.3 (0.6) n=8
NS
4 (19.0)
7 (33.3)
16 (76.2)
< 0.05
Clinical measure Mean time postpartum, months (SD)
P
Measures of weight
Mean waist circumference, cm (SD) Mean measured cardiovascular risk factors (SD)
Lifestyle behaviours, n (%) Participation in physical activity Balanced diet
—
3 (14.3)
3 (14.3)
NS
Current smoker
—
1 (4.8)
1 (4.8)
NS
Breastfeeding
—
10 (47.6)
5 (23.8)
NS
n = 21 unless otherwise specified. NS: not significant; BP: blood pressure; LDL: low density lipoprotein; HDL: high density lipoprotein
at six months postpartum and are subsequently referred for subspecialist medical care as required.25,26 However, both that clinic and ours have identified increased CVD risk in women with PE, and support the need for dedicated cardiovascular risk reduction strategies. Several key findings of our study warrant further discussion. First, one of the encouraging findings of this study is an improvement in physical activity in women at risk. Before pregnancy, only 14% of women were participating in any regular physical activity, and this increased to 76% with regular physical activity at a mean 4.4 months postpartum (P < 0.05). This finding suggests that the PPPEC’s use of individualized achievable goals focused on each woman’s preferences for physical activity may be an effective strategy in this early postpartum period. A longer duration of follow-up with physical activity levels measured directly will be needed to determine whether these improvements in physical activity using this strategy are maintained and whether Health Canada’s physical activity 334 l APRIL JOGC AVRIL 2015
recommendations are achieved. Of note, the RAH PPPEC exercise intervention (i.e., education and goal setting) differs significantly from that in a recent study by Scholten et al., in which an intensive in-person, laboratory-based aerobic exercise program was evaluated in women with PE.27 These authors demonstrated that when women were enrolled at 6 to 12 months postpartum there were significant changes in CVD risk factors and measures of cardiovascular function after this 12-week intensive exercise program. However, long-term participant adherence, cost-effectiveness, and the feasibility of implementing this type of supervised exercise program into routine clinical practice were not assessed.27 Further studies on strategies to implement exercise programs into routine clinical practice for women with PE are required. Second, our study demonstrated a trend towards improvements in weight and BMI over time. This finding must be interpreted with caution because of the lack of a comparison group to determine whether these findings
Cardiovascular Risk Reduction and Weight Management at a Hospital-Based Postpartum Preeclampsia Clinic
were due to the educational intervention or due to normal postpartum physiologic changes. However, this trend may be important, as data from the prospective observational Canadian PE-NET cohort study demonstrate that most women with PE actually gain weight by oneyear postpartum.4 There was no difference in baseline pre-pregnancy weight in the PE-NET study, but at oneyear postpartum the mean weight for women with PE was 77.3 ± 20.2 kg compared with 71.8 ± 14.7 kg in women without PE (P < 0.01).4 In addition, 38.6% of women with PE were obese at one-year postpartum compared with 18.6% of women without PE (P < 0.05).4 A longer duration of follow-up of the RAH PPPEC cohort will be necessary to determine whether this trend in weight loss continues up to one-year postpartum, as others have demonstrated that the majority of women (60%) have fluctuations in their weight (experiencing both gains and losses) within the first-year postpartum.28 Third, we found relatively low rates of breastfeeding: 47.6% of the cohort were breastfeeding at 1.8 months postpartum and 23.8% at 4.4 months postpartum, similar to other reports of low rates of initiation and continued breastfeeding in women with PE.29 This finding is important, because although the effects of breastfeeding on weight loss are controversial,30 a longer duration of breastfeeding has been associated with a reduction in CVD in a large epidemiologic study of over 89 000 women.31 Clinical studies have also demonstrated a shorter duration of breastfeeding to be associated with measures of atherosclerosis.32 Further studies are needed to determine if strategies to increase the rate and duration of breastfeeding may be a low-cost intervention to improve the long-term cardiovascular health of women with PE. Fourth, we found a reduction in the number of women requiring antihypertensive therapy at 4.4 months postpartum (from 42.9% to 19.0%; P < 0.05), and a nonsignificant reduction in both systolic and diastolic blood pressures. While these improvements in blood pressure appear promising, these results must also be interpreted with caution without a comparison group, as blood pressure gradually reduces over the first few months postpartum in women with PE due to many physiological changes.33 Without a comparison arm receiving no intervention, it is difficult to distinguish between the changes resulting from attending the interdisciplinary clinic and normal postpartum changes. Another important finding of this study is the low rate of referral to the PPPEC (104 women over 2.5 years). The low referral rate appeared to be due to a lack of
advertising for the clinic in the early phases, having many women living out of the region (as RAH is a tertiary care referral centre), and having limited clinic resources. This low referral rate, however, highlights the importance of having a systematic process to ensure that all women with PE are referred for postpartum counselling about CVD risk and its potential reduction. An example of such a systematic system is the referral process for the Kingston Maternal Health Clinic, located in Kingston General Hospital in Ontario; all women with pregnancy complications (outlined above) who deliver at that hospital are referred to the clinic via a standardized postpartum order set.25 Such a systematic referral system may help to ensure that more women with PE are advised about CVD prevention strategies. However, even among the women who attended the RAH PPPEC the rate of participant follow-up was low. As outlined in the Figure, only 75% of the subset of women with PE referred for an initial consultation in the PPPEC actually attended their first appointment. This is of vital importance, as it suggests that a large proportion of women with PE delivering at the Royal Alexandra Hospital do not receive information pertaining to the future health implications of PE. Although low rates of participation are common in studies of postpartum lifestyle interventions,34,35 additional reasons for limited participation, such as having a baby in the NICU, competing family demands, scheduling difficulties, and the need for in-person attendance, may be present.36 Further studies of barriers to attendance would assist postpartum clinics in developing proactive strategies to promote participation. An Ontario study suggested that fewer than 10% of Canadian women with PE report receiving information from their obstetrical care providers about the risk of future chronic hypertension after PE.37 Hence, potential strategies to target and educate these women must be considered. In addition, our findings demonstrate that only 51% of women who attend the initial consultation return for future in-person visits. This is a common finding in postpartum lifestyle studies35 and may reflect the unique challenges of women in the postpartum period as they attempt to balance the needs of a young family with their own health.36 Hoedjes et al. conducted a qualitative study of the preferences for postpartum lifestyle interventions in women with PE.36 Women with PE reported that they preferred a combination of modes of delivery of lifestyle interventions (i.e., in-person, computer and/or telephone contacts) because they had difficulty attending exclusively in-person visits.36 Therefore, these data suggest that for lifestyle programs to be optimally effective in the early APRIL JOGC AVRIL 2015 l 335
Women’s Health
postpartum period, programs should consider using multiple forms of delivery of information. The main limitations of this study are the small sample size of 21 women, the relatively short duration of followup, and the lack of a comparison arm. Of the 21 women, fewer than one half had serum lipids and glycemic status measured on two occasions (Table 2); therefore, this study was not able to evaluate changes in these cardiovascular risk factors accurately. This small sample size may have also contributed to the lack of statistical significance associated with the improvements in blood pressure, weight, and BMI over time. While the study included women who had a minimum of six months of follow-up in the PPPEC, the average timing of the visit closest to the six-month followup visit was actually 4.4 ± 1.4 months postpartum, which likely reflects the limited availability of participants. This is a relatively short time period in which to determine potential benefits on cardiovascular risk factors and lifestyle habits. Consequently, a longer duration of follow-up is planned. Finally, the retrospective design of the study may have limited collection of other clinically relevant information. Despite our study’s limitations, it provides valuable information on the implementation and effectiveness of lifestyle counselling programs that may be used to design clinical future studies. We plan in the future to: 1. Compare the changes in cardiovascular risk factors in women attending the PPPEC with the results of an ongoing prospective observational cohort study of women with PE4,26; 2. Refine the interdisciplinary lifestyle counselling intervention by supplementing the information on physical activity and nutrition; and 3. Prospectively collect clinical data on women attending the PPPEC for a longer time in order to better evaluate the changes in weight, cardiovascular risk factors, and lifestyle behaviours in women with PE. CONCLUSION
This study has provided preliminary data on the effectiveness of a longitudinal interdisciplinary clinic approach to early postpartum cardiovascular risk reduction in Canadian women with recent PE. This intervention, focused on counselling women about lifestyle modifications and setting individual goals for changing behaviour, resulted in improvements in physical activity and trends towards improvements in weight, BMI, and blood pressure at a mean 4.4 months postpartum. This study provides support for future lifestyle intervention studies in postpartum 336 l APRIL JOGC AVRIL 2015
women with recent PE as a strategy for prevention of future CVD. ACKNOWLEDGEMENTS
This study was funded by a research grant from the Royal Alexandra Hospital Nutrition Research Fund. The authors wish to thank the Royal Alexandra Hospital Women’s Health Program (Lois Hole Hospital for Women), Ms Becky Leung, MSc for statistical assistance, and Ms Mariel Fajer Gomez, MSc, RD for assistance with data extraction. REFERENCES 1. Williams D. Pregnancy: a stress test for life. Curr Opin Obstet Gynecol 2003;15(6):465–71. 2. Williams D. Long-term complications of preeclampsia. Semin Nephrol 2011;31:111–22. 3. Bellamy L, Casas J-P, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ 2007;335:(7627):974. Epub 2007 Nov 1. Review. 4. Smith GN, Walker MC, Liu A, Shi WW, Swansburg M, Ramshaw H, et al.; for the Pre-Eclampsia New Emerging Team (PE-NET). A history of preeclampsia identifies women who have underlying cardiovascular risk factors. Am J Obstet Gynecol 2009;200:58.e1–e8. 5. Smith GN, Pudwell J, Walker MC, Wen S-W; Pre-Eclampsia New Emerging Team (PE-NET). Risk estimation of metabolic syndrome at one and three years after a pregnancy complicated by preeclampsia. J Obstet Gynaecol Can 2012;34(9):836–41. 6. Feig DS, Shah BR, Lipscombe LL, Wu CF, Ray JG, Lowe J, et al. Preeclampsia as a risk factor for diabetes: a population-based cohort study. PLoS Med 2013;10(4):e1001425. doi: 10.1371/journal.pmed. 7. Ray JG, Vermeulen MJ, Schull MJ, Redelmeier DA. Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study. Lancet 2005;366:1797–803. 8. McDonald SD, Malinowski A, Zhou Q, Yusuf S, Devereaux PJ. Cardiovascular sequelae of preeclampsia / eclampsia: a systematic review and meta-analysis. Am Heart J 2008;156:918–30. 9. Berks D, Hoedjes M, Raat H, Duvekot JJ, Steegers EA, Habbema JD. Risk of cardiovascular disease after pre-eclampsia and the effect of lifestyle interventions: a literature-based study. BJOG 2013;120(8):924–31. doi: 10.1111/471–0528.12191. 10. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346(6):393–403. 11. Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P; Hypertension Guideline Committee. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. SOGC Clinical Practice Guideline no. 307, May 2014. J Obstet and Gynaecol Can 2014;36(5):416–38. 12. Mosca L, Benjamin EJ, Berra K, Benzanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update. Circulation 2011;123:1243–62. 13. Preeclampsia Foundation. Preeclampsia and heart disease. Melbourne, FL: Preeclampsia Foundation; 2012; Available at: http://wwwpreeclampsia.org. Accessed February 29, 2012.
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18. Canadian Society for Exercise Physiology. Canadian physical activity guidelines. Ottawa: CSEP; 2011. Available at: http://www.csep.ca/ guidelines. Accessed February 19, 2014.
30. Neville C, McKinley M, Holmes V, Spence D, Woodside J. The relationship between breastfeeding and postpartum weight change-a systematic review and critical evaluation. Int J Obes (Lond) 2014;38(4):577–90.
19. Colley RC, Garriguet D, Janssen I, Craig CL, Clarker J, Tremblay MS. Physical activity of Canadian adults: accelerometer results from the 2007 to 2009 Canadian Health Measures Survey. Ottawa: Statistics Canada; 2011. Contract No.: 82–003-XPE. 20. Statistics Canada. Canadian Community Health Survey 2011–2012. Ottawa: Statistics Canada; 2013. Available at: http://wwwstatcan.gc.ca/ pub/82–625-x/82–625-x2013001-eng.htm. Accessed February 19, 2014. 21. Hoedjes M, Berks D, Vogel I, Franx A, Visser W, Duvekot JJ, et al. Effect of postpartum lifestyle interventions on weight loss, smoking cessation, and prevention of smoking relapse: a systematic review. Obstet Gynecol Surv 2010;65(10):631–2. 22. Firoz T, Melnik T. Postpartum evaluation and long term implications. Best Pract Res Clin Obstet Gynaecol 2011;25:549–61. 23. Magee LA, Helewa M, Moutquin J-M, von Dadelszen P; SOGC Hypertension Guideline Committee. Diagnosis, evaluation and management of the hypertensive disorders of pregnancy. SOGC Clinical Practice Guideline no. 206, March 2008. J Obstet Gynaecol Can 2008;30(3 Suppl 1):1–52. 24. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377–81. 25. Smith GN, Pudwell J, Roddy M. The maternal health clinic: a new window of opportunity for early heart disease risk screening and intervention for women with pregnancy complications. J Obstet Gynaecol Can 2013;35(9):831–9. 26. Cusimano MC, Pudwell J, Roddy M, Cho C-KJ, Smith GN. The maternal health clinic: an initiative for cardiovascular risk identification
31. Stuebe AM, Michels KB, Willett WC, Manson JE, Rexrode KM, Rich-Edwards JW. Duration of lactation and incidence of myocardial infarction in middle to late adulthood. Am J Obstet Gynecol 2009;200(2):138.e1–8. doi: 10.1016/j.ajog.2008.10.001. 32. Schwarz EB, McClure CK, Tepper PG, Thurston R, Janssen I, Matthews KA, et al. Lactation and maternal measures of subclinical cardiovascular disease. Obstet Gynecol. 2010;115(1):41–8. doi: 10.1097/AOG.0b013e3181c5512a. 33. Berks D, Steegers EAP, Molas M, Visser W. Resolution of hypertension and proteinuria after preeclampsia. Obstet Gynecol 2009;114(6):1307–14. 34. Ferrara A, Hedderson MM, Albright CL, Ehrlich SF, Quesenberry CP Jr, Peng T, et al. A pregnancy and postpartum lifestyle intervention in women with gestational diabetes mellitus reduces diabetes risk factors. A feasibility randomized control trial. Diabetes Care 2011;34:1519–25. 35. Kuhlmann AK, Dietz PM, Galavotti C, England LJ. Weight-management interventions for pregnant or postpartum women. Am J Prev Med 2008;34(6):523–8. 36. Hoedjes M, Berks D, Vogel I, Duvekot JJ, Oenema A, Franx A, et al. Preferences for postpartum lifestyle counseling among women sharing an increased cardiovascular and metabolic risk: a focus group study. Hypertens Pregnancy 2011;30:83–92. 37. MacDonald SE, Walker MC, Ramshaw H, Godwin M, Chen X-K, Smith GN. Hypertensive disorders of pregnancy and long-term risk of hypertension: what do Ontario prenatal care providers know, and what do they communicate? J Obstet Gynaecol Can 2007;29(9):705–10.
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Cardiovascular Risk Reduction and Weight Management at a Hospital-Based Postpartum Preeclampsia Clinic Rahim Janmohamed, MD,1 Erin Montgomery-Fajic, BASc,2 Winnie Sia, MD,1,3 Debbie Germaine, BScN, NP,4 Jodi Wilkie, BSc Pharm,4 Rshmi Khurana, MD,1,3 Kara A. Nerenberg, MD, MSc5 Department of Obstetrics and Gynecology, University of Alberta, Edmonton AB
1
Nutrition Services, Alberta Health Services, Edmonton AB
2
Department of Medicine, University of Alberta, Edmonton AB
3
Alberta Health Services, Edmonton AB
4
Ottawa Hospital Research Institute, University of Ottawa, Ottawa ON
5
Abstract
Résumé
Objective: Women who develop preeclampsia during pregnancy are at high risk of developing future chronic diseases, including premature cardiovascular disease. We have established an interdisciplinary clinic that aims to prevent cardiovascular disease through educational counselling focused on lifestyle modifications in the early postpartum period. The objective of this study was to evaluate changes in weight and cardiovascular risk factors in participating women after six months of attendance at the clinic.
Objectif : Les femmes qui en viennent à connaître une prééclampsie pendant la grossesse sont exposées à un risque élevé d’en venir par la suite à présenter des maladies chroniques, dont la maladie cardiovasculaire prématurée. Nous avons mis sur pied une clinique interdisciplinaire qui vise à prévenir la maladie cardiovasculaire par l’offre de services de counseling pédagogique axés sur les modifications à apporter au mode de vie aux débuts de la période postpartum. Cette étude avait pour objectif d’évaluer les modifications du poids et des facteurs de risque cardiovasculaire chez les participantes, après six mois de consultations à la clinique.
Methods: We conducted a retrospective chart review of women who had a pregnancy complicated by preeclampsia, and who subsequently attended the Postpartum Preeclampsia Clinic. Study subjects had baseline assessments of lifestyle, physical, and laboratory parameters. Individualized goals for cardiovascular risk reduction and lifestyle were established, centering on physical activity and dietary modifications. The primary outcome was change in weight. Results: Over the study period, 21 women were seen for a minimum of six months of follow-up. At an average (± SD) of 4.4 ± 1.4 months postpartum, subjects showed a non-significant improvement in weight (mean weight loss of 0.4 ± 4.5 kg) and BMI (mean decrease in BMI 0.1 ± 1.7 kg/m2). Physical activity improved significantly, from 14% of subjects participating in physical activity before pregnancy to 76% at a mean of 4.4 months postpartum. Conclusion: This study has demonstrated the early benefits of a longitudinal interdisciplinary intervention with counselling about lifestyle modifications for prevention of cardiovascular disease in women with recent preeclampsia. A study with a larger sample size and longer duration of follow-up is planned to confirm these findings.
Key Words: Preeclampsia, postpartum care, nutrition, vascular disease, health promotion and prevention, weight management Competing Interests: None declared. Received on September 9, 2014 Accepted on November 10, 2014
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Méthodes : Nous avons mené une analyse rétrospective des dossiers des femmes dont la grossesse avait été compliquée par la prééclampsie et qui avaient par la suite fréquenté la Postpartum Preeclampsia Clinic. Pour déterminer les paramètres de départ, les participantes à l’étude ont été soumises à des évaluations du mode de vie, à des examens physiques et à des analyses de laboratoire. Des objectifs personnalisés en matière de réduction du risque cardiovasculaire et de modification du mode de vie ont été établis, le tout étant axé sur l’activité physique et les modifications du régime alimentaire. La modification du poids constituait le critère d’évaluation principal. Résultats : Au cours de la période d’étude, 21 femmes ont fait l’objet d’un suivi d’une durée minimale de six mois. À 4,4 ± 1,4 mois postpartum en moyenne (± σ), les participantes présentaient une amélioration non significative en matière de poids (perte pondérale moyenne de 0,4 ± 4,5 kg) et d’IMC (diminution moyenne de l’IMC de 0,1 ± 1,7 kg/m2). Le niveau d’activité physique a connu une amélioration significative, passant de 14 % des participantes pratiquant des activités physiques avant la grossesse à 76 % après 4,4 mois postpartum en moyenne. Conclusion : Cette étude a démontré les avantages précoces d’une intervention interdisciplinaire longitudinale, s’accompagnant de services de counseling sur les modifications à apporter au mode de vie, pour assurer la prévention des maladies cardiovasculaires chez des femmes ayant récemment connu une prééclampsie.
Cardiovascular Risk Reduction and Weight Management at a Hospital-Based Postpartum Preeclampsia Clinic
Nous prévoyons mener une étude comptant un échantillon plus large et un suivi de plus longue durée, en vue de confirmer ces constatations. J Obstet Gynaecol Can 2015;37(4):330–337
INTRODUCTION
T
he occurrence of preeclampsia during pregnancy identifies a group of women who are at increased risk of developing future chronic diseases (e.g., metabolic syndrome, obesity, type 2 diabetes, chronic hypertension, kidney disease, and premature cardiovascular disease).1–8 Many of these chronic diseases may be largely prevented through implementation of simple postpartum lifestyle interventions.9,10 Accordingly, several Canadian and international organizations have recommended routine postpartum follow-up of women with PE to provide educational counselling regarding healthy lifestyle activities for chronic disease prevention.11–15 There are two components of these postpartum lifestyle recommendations. The first is loss of all gestational weight and achievement of a normal BMI of 18 to 24.9 kg/m2.13,14,16 The second is a set of specific lifestyle recommendations which mirror Health Canada’s minimum lifestyle recommendations for nutrition (7 to 8 servings of fruits and vegetables per day)17 and physical activity (150 minutes of moderate to vigorous physical activity per week).18 Despite these recommendations, observational data suggest that the majority of Canadian women are not meeting these basic health prevention guidelines.19,20 To date, few studies have assessed the long-term effectiveness of lifestyle interventions (either exercise or dietary modifications) for CVD prevention in postpartum women who had PE. Such women are among those at highest risk of developing premature CVD.14,21,22 This study examined the effects of longitudinal attendance at an interdisciplinary clinic providing lifestyle educational counselling in the early postpartum period on cardiovascular risk factors and weight management in Canadian women with recent PE. Specific study objectives were to assess changes in cardiovascular risk factors and ABBREVIATIONS CVD
cardiovascular disease
PE-NET Pre-Eclampsia New Emerging Team PE
preeclampsia
PPPEC The Postpartum Preeclampsia Clinic RAH
Royal Alexandra Hospital
SD
standard deviation
weight in subjects after six months of follow-up, and to examine changes in lifestyle behaviours in subjects from baseline to six months of follow-up. METHODS
The Postpartum Preeclampsia Clinic at the Royal Alexandra Hospital in Edmonton, Alberta, is an interdisciplinary clinic that was established in September 2010. PPPEC team members include an obstetric medicine physician (general internist), a nurse practitioner, a registered dietitian, and a pharmacist (online eAppendix 1). Medical trainees (clinical fellows and residents) and students of other health disciplines attend the clinic in rotation. Women with a recent diagnosis of PE are assessed and followed longitudinally in this clinic. The main goals of the PPPEC are: 1. to educate women about the future health implications of PE, focusing on the risk of PE in subsequent pregnancies and the risk of premature CVD; 2. to assess modifiable cardiovascular risk factors; and 3. to improve cardiovascular risk factors and achieve weight management primarily through counselling about lifestyle modifications (diet and exercise), with supplemental use of pharmacologic therapies when indicated. In general, women with PE are referred by their obstetrical care provider to the PPPEC at the time of discharge from hospital after delivery. At the first clinic visit, women view a 20-minute computerized presentation about preeclampsia and future heart health which introduces the importance of lifestyle modifications to reduce cardiovascular risk. They then complete a health profile (a two-page questionnaire) that provides the clinic team with information about the woman’s PE history, medical history (including standard cardiovascular risk factors), family history, medications, and social history (tobacco, alcohol, caffeine, recreational drugs, exercise, and stress). Exercise is recorded on the selfreported questionnaire as whether the woman participated in any form of regular exercise before pregnancy. The nurse practitioner or obstetric medicine specialist reviews this information and obtains any additional information directly from the patient or from the hospital chart. A standardized physical examination is performed, including measurement of height, weight, waist circumference, and blood pressure. Vascular risk is assessed at the baseline visit by examining glycemic status (hemoglobin A1C and fasting blood glucose level or a 75 gram oral glucose tolerance test) and serum lipid levels. These investigations are repeated after six months if indicated. Resolution of preeclampsia is confirmed at the baseline visit by performing a CBC APRIL JOGC AVRIL 2015 l 331
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PPEC flow diagram PPEC patients scheduled September 3, 2010, to March 18, 2013 104 patients scheduled for initial consult cococonsultconsult 104 patients scheduled for initial consult
78 patients attended initial consult
26 patients did not attend initial consult (no shows)
38 patients did not return for a follow-up appointment
40 patients returned for follow-up appointments 19 patients had less than 6 months of clinic follow-up 21 patients had 6 months or more of clinic followup and were included in the study
and measuring serum creatinine, serum AST, serum ALT, and spot urine protein to creatinine ratio. All other investigations (e.g., ECG or echocardiogram) are ordered on an individual basis. At the initial visit, women meet individually with the team members. The dietitian assesses each woman’s diet and provides counselling at the initial visit and as needed at follow-up visits. Women are educated in reading food labels, and in the optimal dietary intake of fat, sodium, and fibre. Simple nutritional goals are established through individualized discussions with each woman; these goals generally are to achieve a modest weight reduction of one half to one pound per week. The clinic pharmacist educates patients about new medications and counsels women about smoking cessation. The pharmacist also monitors and adjusts medications for hypertension, hyperlipidemia, diabetes, and smoking cessation as appropriate. The obstetric medicine specialist or nurse practitioner assesses each woman for other medical issues. All team members counsel women about the importance of regular physical activity and offer suggestions on integration of physical activity into daily life. Frequency, duration, and type of physical activities are listed as goals and are recorded in the follow-up visits. Finally, the team formulates an integrated management plan individualized for each woman. At the end of each clinic visit, participants are given a paper copy of the PPPEC Action Plan (online eAppendix 2). In this document, women set individualized goals for each of the 332 l APRIL JOGC AVRIL 2015
following: blood pressure, serum lipid levels, blood glucose level, tobacco use, dietary changes, physical activity, and weight loss. These goals are reviewed and updated at each visit. Information regarding each woman’s clinical status and goals are summarized in a letter and sent to her family physician. Participants are generally seen in the clinic for follow-up every three to six months for the first year postpartum. We included in this chart review all women attending the PPPEC who met the following eligibility criteria: 1. were aged 18 years or older; 2. attended the PPPEC for a minimum of six months during the study period (September 3, 2010, to March 18, 2013); and 3. had a confirmed diagnosis of PE, eclampsia or HELLP (hemolysis, elevated liver enzymes, or low platelets) syndrome (using the Society of Obstetricians and Gynaecologists of Canada 2008 Guidelines definitions23) in the most recent pregnancy. A standardized electronic method for data extraction using REDCap data management system24 was developed and tested for inter-rater reliability. The following data were collected from the hospital and PPPEC charts: patient demographics, clinical measurements, obstetrical history, results of investigations, and treatment goals for the baseline visit and all follow-up visits up to six months.
Cardiovascular Risk Reduction and Weight Management at a Hospital-Based Postpartum Preeclampsia Clinic
Baseline participant characteristics are presented as means with standard deviations or as medians with interquartile range for continuous variables, and as counts with percentages for categorical variables. Comparisons between groups were made using the Student t test and Kruskal-Wallis test for continuous variables and chisquare tests for categorical variables. Statistical significance was predetermined at a P value of < 0.05. All statistical analyses were performed using SAS software, version 9.3 (SAS Institute Inc., Cary, NC). This study was approved by the Research Ethics Board at the University of Alberta. RESULTS
As outlined in the Figure, 78 women were seen at least once in the PPPEC during the study period. Of these, 21 women were seen for a minimum of six months of followup and met the eligibility criteria. The initial clinic visit was at a mean (± SD) of 1.8 ± 3.0 months postpartum. The visit closest to the six-month follow-up period occurred at a mean of 4.4 ± 1.8 months postpartum. The main characteristics of the PPPEC cohort are summarized in Table 1. Women seen in the PPPEC were an average of 29.1 ± 3.6 years old (SD), 66.7% were primigravid, and 85.7% had singleton pregnancies. Overall, PE was detected before 34 weeks in 66.7% of women, and the mean gestational age at delivery of the entire cohort was 31.8 ± 4.0 weeks. In addition, two thirds of women required Caesarean section for delivery. Similarly, two thirds of women received magnesium sulfate for eclampsia prevention, but one woman (4.8%) had developed eclampsia. Before pregnancy, the mean self-reported weight of the PPPEC cohort was 81.3 ± 25.0 kg, and mean BMI was 31.1 ± 10.2 kg/m2. At the first postpartum visit (at a mean 1.8 months postpartum), the mean weight in the cohort was 85.7 ± 24.4 kg and mean BMI was 32.7 ± 9.8 kg/m2. After an average of 4.4 ± 1.4 months postpartum, there was a non-significant mean weight loss of 0.4 ± 4.5 kg and mean decrease in BMI of 0.1 ± 1.7 kg/m2 (Table 2). Before pregnancy, four of 21 women (19%) had a history of chronic hypertension, one woman (4.8%) smoked, and one woman (4.8%) had a family history of cardiovascular disease. None in the cohort had pre-pregnancy dyslipidemia, pre-pregnancy type 1 or 2 diabetes, or gestational diabetes. At the first postpartum clinic visit, the mean blood pressures recorded were 123.0 ± 12.1 mmHg systolic and 81.3 ± 9.6 mmHg diastolic; 43% of women were taking antihypertensive medication. At a mean of 4.4 months postpartum, there was a non-significant reduction
Table 1. Participant characteristics at baseline assessment Overall cohort (N = 21)
Participant characteristic Demographics Mean age, years (SD)
29.1 (3.6)
Married or common-law, n (%)
16 (76.2)
Obstetrical history Primigravid, n (%)
14 (66.7)
Prior history of preeclampsia, n (%)
1 (4.8)
Delivery history Mean gestational age at delivery, weeks (SD)
31.8 (4.0)
Caesarean section, n (%)
14 (66.7)
Baby currently in NICU, n (%)
12 (57.7)
Cardiovascular risk factors Chronic hypertension, n (%)
4 (19.0)
Dyslipidemia, n (%)
0
Pre-pregnancy DM or GDM, n (%)
0
Current smoker, n (%)
1 (4.8)
Family history of CVD, n (%)
8 (38.1)
DM: diabetes mellitus (type 1 or 2); GDM: gestational diabetes mellitus
in mean blood pressures; however, only four women (19%) were still taking any antihypertensive medication. Too few women had data available on fasting lipid and glucose levels at both baseline and follow-up assessments to assess changes accurately. Fourteen percent of women (3/21) reported participating in any regular physical activity prior to pregnancy and 19% (4/21) reported participating in any regular physical activity during pregnancy. This increased to 33% (7/21) at the first clinic visit, and to 76.2% (16/21) at a mean of 4.4 months postpartum (P < 0.05) (Table 2). There were no significant changes in the proportion of women who achieved a balanced diet between baseline (14.3%) and 4.4 months postpartum (14.3%). Fewer women breastfed at the 4.4 month follow up compared to the initial visit (23.8% vs. 47.6%, not significant). DISCUSSION
This study has demonstrated the effectiveness of longitudinal counselling by an interdisciplinary team about lifestyle modifications in the early postpartum period in women with recent PE as an opportunity for CVD prevention. Our longitudinal approach to vascular risk reduction is slightly different from the approach in the Kingston Maternal Health Clinic, in which women with pregnancy complications (e.g., PE, gestational diabetes, preterm birth) are seen for cardiovascular risk assessment APRIL JOGC AVRIL 2015 l 333
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Table 2. Changes in clinical measures over time Pre-pregnancy
Baseline visit
Visit closest to 6 months of follow-up
—
1.8 (3.0)
4.4 (1.4)
Mean weight, kg (SD)
81.3 (25.0)
85.7 (24.4)
84.7 (24.0)
NS
Mean BMI, kg/m2 (SD)
31.1 (10.2)
32.7 (9.8)
32.3 (9.5)
NS
—
101.6 (16.2)
102.7 (21.9)
NS
Systolic BP, mmHg
—
123.0 (12.1)
119.1 (8.9)
NS
Diastolic BP, mmHg
—
81.3 (9.6)
79.3 (7.9)
NS
Total cholesterol, mmol/L
—
5.1 (1.1) n=9
4.8 (1.1) n = 11
NS
LDL-cholesterol, mmol/L
—
2.9 (0.7) n=9
2.7 (0.6) n = 12
NS
HDL-cholesterol, mmol/L
—
1.6 (0.2) n=8
1.3 (0.3) n = 12
NS
Triglycerides, mmol/L
—
1.8 (1.3) n=9
1.9 (1.1) n = 11
NS
Total cholesterol/HDL-cholesterol, ratio
—
3.3 (0.9) n=9
4.0 (0.9) n = 11
NS
Fasting glucose, mmol/L
—
4.9 (0.5) n=7
5.3 (0.6) n=8
NS
4 (19.0)
7 (33.3)
16 (76.2)
< 0.05
Clinical measure Mean time postpartum, months (SD)
P
Measures of weight
Mean waist circumference, cm (SD) Mean measured cardiovascular risk factors (SD)
Lifestyle behaviours, n (%) Participation in physical activity Balanced diet
—
3 (14.3)
3 (14.3)
NS
Current smoker
—
1 (4.8)
1 (4.8)
NS
Breastfeeding
—
10 (47.6)
5 (23.8)
NS
n = 21 unless otherwise specified. NS: not significant; BP: blood pressure; LDL: low density lipoprotein; HDL: high density lipoprotein
at six months postpartum and are subsequently referred for subspecialist medical care as required.25,26 However, both that clinic and ours have identified increased CVD risk in women with PE, and support the need for dedicated cardiovascular risk reduction strategies. Several key findings of our study warrant further discussion. First, one of the encouraging findings of this study is an improvement in physical activity in women at risk. Before pregnancy, only 14% of women were participating in any regular physical activity, and this increased to 76% with regular physical activity at a mean 4.4 months postpartum (P < 0.05). This finding suggests that the PPPEC’s use of individualized achievable goals focused on each woman’s preferences for physical activity may be an effective strategy in this early postpartum period. A longer duration of follow-up with physical activity levels measured directly will be needed to determine whether these improvements in physical activity using this strategy are maintained and whether Health Canada’s physical activity 334 l APRIL JOGC AVRIL 2015
recommendations are achieved. Of note, the RAH PPPEC exercise intervention (i.e., education and goal setting) differs significantly from that in a recent study by Scholten et al., in which an intensive in-person, laboratory-based aerobic exercise program was evaluated in women with PE.27 These authors demonstrated that when women were enrolled at 6 to 12 months postpartum there were significant changes in CVD risk factors and measures of cardiovascular function after this 12-week intensive exercise program. However, long-term participant adherence, cost-effectiveness, and the feasibility of implementing this type of supervised exercise program into routine clinical practice were not assessed.27 Further studies on strategies to implement exercise programs into routine clinical practice for women with PE are required. Second, our study demonstrated a trend towards improvements in weight and BMI over time. This finding must be interpreted with caution because of the lack of a comparison group to determine whether these findings
Cardiovascular Risk Reduction and Weight Management at a Hospital-Based Postpartum Preeclampsia Clinic
were due to the educational intervention or due to normal postpartum physiologic changes. However, this trend may be important, as data from the prospective observational Canadian PE-NET cohort study demonstrate that most women with PE actually gain weight by oneyear postpartum.4 There was no difference in baseline pre-pregnancy weight in the PE-NET study, but at oneyear postpartum the mean weight for women with PE was 77.3 ± 20.2 kg compared with 71.8 ± 14.7 kg in women without PE (P < 0.01).4 In addition, 38.6% of women with PE were obese at one-year postpartum compared with 18.6% of women without PE (P < 0.05).4 A longer duration of follow-up of the RAH PPPEC cohort will be necessary to determine whether this trend in weight loss continues up to one-year postpartum, as others have demonstrated that the majority of women (60%) have fluctuations in their weight (experiencing both gains and losses) within the first-year postpartum.28 Third, we found relatively low rates of breastfeeding: 47.6% of the cohort were breastfeeding at 1.8 months postpartum and 23.8% at 4.4 months postpartum, similar to other reports of low rates of initiation and continued breastfeeding in women with PE.29 This finding is important, because although the effects of breastfeeding on weight loss are controversial,30 a longer duration of breastfeeding has been associated with a reduction in CVD in a large epidemiologic study of over 89 000 women.31 Clinical studies have also demonstrated a shorter duration of breastfeeding to be associated with measures of atherosclerosis.32 Further studies are needed to determine if strategies to increase the rate and duration of breastfeeding may be a low-cost intervention to improve the long-term cardiovascular health of women with PE. Fourth, we found a reduction in the number of women requiring antihypertensive therapy at 4.4 months postpartum (from 42.9% to 19.0%; P < 0.05), and a nonsignificant reduction in both systolic and diastolic blood pressures. While these improvements in blood pressure appear promising, these results must also be interpreted with caution without a comparison group, as blood pressure gradually reduces over the first few months postpartum in women with PE due to many physiological changes.33 Without a comparison arm receiving no intervention, it is difficult to distinguish between the changes resulting from attending the interdisciplinary clinic and normal postpartum changes. Another important finding of this study is the low rate of referral to the PPPEC (104 women over 2.5 years). The low referral rate appeared to be due to a lack of
advertising for the clinic in the early phases, having many women living out of the region (as RAH is a tertiary care referral centre), and having limited clinic resources. This low referral rate, however, highlights the importance of having a systematic process to ensure that all women with PE are referred for postpartum counselling about CVD risk and its potential reduction. An example of such a systematic system is the referral process for the Kingston Maternal Health Clinic, located in Kingston General Hospital in Ontario; all women with pregnancy complications (outlined above) who deliver at that hospital are referred to the clinic via a standardized postpartum order set.25 Such a systematic referral system may help to ensure that more women with PE are advised about CVD prevention strategies. However, even among the women who attended the RAH PPPEC the rate of participant follow-up was low. As outlined in the Figure, only 75% of the subset of women with PE referred for an initial consultation in the PPPEC actually attended their first appointment. This is of vital importance, as it suggests that a large proportion of women with PE delivering at the Royal Alexandra Hospital do not receive information pertaining to the future health implications of PE. Although low rates of participation are common in studies of postpartum lifestyle interventions,34,35 additional reasons for limited participation, such as having a baby in the NICU, competing family demands, scheduling difficulties, and the need for in-person attendance, may be present.36 Further studies of barriers to attendance would assist postpartum clinics in developing proactive strategies to promote participation. An Ontario study suggested that fewer than 10% of Canadian women with PE report receiving information from their obstetrical care providers about the risk of future chronic hypertension after PE.37 Hence, potential strategies to target and educate these women must be considered. In addition, our findings demonstrate that only 51% of women who attend the initial consultation return for future in-person visits. This is a common finding in postpartum lifestyle studies35 and may reflect the unique challenges of women in the postpartum period as they attempt to balance the needs of a young family with their own health.36 Hoedjes et al. conducted a qualitative study of the preferences for postpartum lifestyle interventions in women with PE.36 Women with PE reported that they preferred a combination of modes of delivery of lifestyle interventions (i.e., in-person, computer and/or telephone contacts) because they had difficulty attending exclusively in-person visits.36 Therefore, these data suggest that for lifestyle programs to be optimally effective in the early APRIL JOGC AVRIL 2015 l 335
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postpartum period, programs should consider using multiple forms of delivery of information. The main limitations of this study are the small sample size of 21 women, the relatively short duration of followup, and the lack of a comparison arm. Of the 21 women, fewer than one half had serum lipids and glycemic status measured on two occasions (Table 2); therefore, this study was not able to evaluate changes in these cardiovascular risk factors accurately. This small sample size may have also contributed to the lack of statistical significance associated with the improvements in blood pressure, weight, and BMI over time. While the study included women who had a minimum of six months of follow-up in the PPPEC, the average timing of the visit closest to the six-month followup visit was actually 4.4 ± 1.4 months postpartum, which likely reflects the limited availability of participants. This is a relatively short time period in which to determine potential benefits on cardiovascular risk factors and lifestyle habits. Consequently, a longer duration of follow-up is planned. Finally, the retrospective design of the study may have limited collection of other clinically relevant information. Despite our study’s limitations, it provides valuable information on the implementation and effectiveness of lifestyle counselling programs that may be used to design clinical future studies. We plan in the future to: 1. Compare the changes in cardiovascular risk factors in women attending the PPPEC with the results of an ongoing prospective observational cohort study of women with PE4,26; 2. Refine the interdisciplinary lifestyle counselling intervention by supplementing the information on physical activity and nutrition; and 3. Prospectively collect clinical data on women attending the PPPEC for a longer time in order to better evaluate the changes in weight, cardiovascular risk factors, and lifestyle behaviours in women with PE. CONCLUSION
This study has provided preliminary data on the effectiveness of a longitudinal interdisciplinary clinic approach to early postpartum cardiovascular risk reduction in Canadian women with recent PE. This intervention, focused on counselling women about lifestyle modifications and setting individual goals for changing behaviour, resulted in improvements in physical activity and trends towards improvements in weight, BMI, and blood pressure at a mean 4.4 months postpartum. This study provides support for future lifestyle intervention studies in postpartum 336 l APRIL JOGC AVRIL 2015
women with recent PE as a strategy for prevention of future CVD. ACKNOWLEDGEMENTS
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