Hyagriv Simhan, MD, Director of Maternal-Fetal Medicine at Magee-Womens Hospital talks about high risk pregnancy conditions and how monitoring can help.
Interview conducted by Ivanhoe Broadcast News in February 2019.
You monitor a lot of pregnancy conditions. Could you tell me a little bit about what goes on in a woman’s system in terms of gestational diabetes and hypertension?
HYAGRIV SIMHAN: Gestational diabetes is the new onset of high blood sugars in a pregnant woman. This is different from Type 1 or Type 2 diabetes that men, women, or children can have. Gestational diabetes can occur in early or mid-pregnancy and is a high blood sugar response to the hormones of pregnancy. It complicates about five to 10 percent of pregnancies. There are a variety of risk factors for gestational diabetes that might make some women at higher risk for developing it. Risk factors like obesity or being pregnant with twins are two common ones, but lots of women get gestational diabetes without any known risk factors for it.
What are the risks to the mothers and what are the risks to the unborn?
HYAGRIV SIMHAN: We care about gestational diabetes for both mothers and babies, those risks are both short-term and long or medium-term. The short-term consequences of gestational diabetes during pregnancy are the higher the woman’s blood sugar is, the higher the baby’s blood sugar is. The higher the baby’s blood sugar, the more rapidly a baby grows, so being excessively large at the time of birth is a complication of poorly-controlled gestational diabetes. The reason we care about this is because of delivery. A baby who is 7 1/2 pounds in general makes for an easier and less-complicated delivery than a baby who is 9 1/2, 10, 10 1/2 pounds. Avoiding excessive size at birth is an important goal of identifying and treating gestational diabetes. We also want to avoid other important problems for babies including low blood sugar after birth and jaundice after birth – both of which might require intensive care for babies and other treatments that we don’t expect to happen in routine pregnancies.
Could you describe why hypertension is an issue in pregnancy and what the risks are for mothers and babies?
HYAGRIV SIMHAN: Gestational hypertension and pre-eclampsia are new-onset high blood pressure during pregnancy. This is in contrast to chronic hypertension which precedes pregnancy or occurs in the first half of pregnancy. Gestational hypertension is when the blood pressure goes up and pre-eclampsia is when blood pressure goes up and there is protein in the urine. There are also other-end organ effects of gestational hypertension and pre-eclampsia. These can affect many organs including the liver, brain, lungs, heart and blood. Pre-eclampsia can range in severity and can occur very early in pregnancy and it can present significant risks related to prematurity and major organ complications for women. Pre-eclampsia during pregnancy and in the postpartum period is one of the leading causes of illness, injury, handicap and death for pregnant and postpartum women around the world and in the US.
Is it important for a woman to have this under control during pregnancy?
HYAGRIV SIMHAN: Yes. Identifying these hypertensive disorders of pregnancy and treating them is essential to minimize complications for mothers and to minimize complications for babies. This is true during pregnancy and lots of energy and effort are placed on that, but it’s also true afterwards because there are longer-term consequences for pre-eclampsia. The likelihood of hypertension and heart disease is higher in women who get pre-eclampsia than in women who don’t have it.
How much higher?
HYAGRIV SIMHAN: It increases the risk of heart attack and stroke over the lifetime about two-and-a-half fold. It’s as powerful a risk factor for those cardiovascular outcomes as cigarette smoking is. I think we all acknowledge how significant of a problem smoking is in heart attack and stroke. However, very few people recognize that pre-eclampsia is a thing or that it is a powerful risk factor for cardiovascular disease.
How would doctors go about monitoring and keeping tabs on patients who were struggling with some of these conditions two years ago?
HYAGRIV SIMHAN: In obstetrics we have paid a lot of attention and I think appropriately during pregnancy to both the mother and the fetus in the antepartum or pre-delivery period, during delivery, and the immediate postpartum period. We’re certainly not optimal or as good as we can be but we’re designed to take care of women in that period. The postpartum period where women transition from having a baby to monitoring, management, and then that handoff to a primary care cardiologist is a gap not only for us but everywhere in our health system. Therefore one of our goals is to facilitate that handoff to make it clear to patients and their providers that this is an important part of their history and that managing it prevents complications for them later on. We have not been as good as we can be at highlighting that, nor have we previously designed systems to manage that handoff and to manage those complications.
What technology have you added here at UPMC that enables doctors to participate in that handoff?
HYAGRIV SIMHAN: The technology that we’ve relied on to help monitor high blood pressures in the postpartum period is relatively simple technology in the world now, which is using mobile device to communicate and use a blood pressure cuff to check blood pressure. Those are two very simple things; the technology itself is not particularly fancy or exciting, what is unique about it is that it’s integrated in a system brought to bear on this group of patients, the kind of operations underneath it, having a system of nurses and physicians responsible for managing blood pressures and medications to identify women who are at risk, and also safely keep women at home if they can avoid coming to the hospital, manage medications remotely and avoid unnecessary visits. That’s the kind of exciting feature of the system. Technology facilitates that but it’s an entire package; a system of operations.
Let’s say that you’re seeing a patient in Newcastle today with hypertension postpartum, that’s a far trip down. Can you explain to me how utilizing phones can help doctors and nurses here know where she’s at in terms of her hypertension?
HYAGRIV SIMHAN: Here at Magee Hospital, when a patient delivers a baby and has had high blood pressure and needs blood pressure medications, she can be enrolled in the program before she leaves the hospital. Our bedside nurses on our mother baby units introduce the program to the patient, talk about the importance of monitoring blood pressure and safely being on medications. When patients enroll in the program they use their own mobile device, and after enrollment they get a link sent to them on their phone. Through that link they can enroll for the program, thus by the time the patient goes home she goes home with a device that is essentially enrolled in the program. That’s her way of communicating with us and the call center. If the patient lives in Newcastle they will still get reminders to check the blood pressure, answer symptom questions, and use the device to communicate with us. The most important element is engagement; picking up the phone and talking to a call center or a provider is very important. We want to be able to identify the patients who need a phone call and not just identify them when they show up in the emergency department. The use of blood pressure monitoring and remote symptom reporting allows us to do that.
How long has this been done? Do you have any indication about what the outcomes would be early on?
HYAGRIV SIMHAN: We’ve been monitoring postpartum blood pressure here by using this system since January of this year. It has almost been a year. We started the program small to make sure that it worked well and that patients and providers would like it. We’ve learned that patients like it a lot as patient engagement and enthusiasm is very high for the program. Providers really like it as well, they are really excited about having their patients signed up or enrolled in the program. We’ve noted several instances where patients have had medications managed, doses adjusted, and medications discontinued that we otherwise wouldn’t have had an opportunity to do without a face-to-face encounter. But in fact we’ve been able to do this with the patients still at home. We’ve also identified patients who needed to come to the hospital for severe hypertension and they were directed to comfort care.
Do you know how many people or how many women are enrolled at this point?
HYAGRIV SIMHAN: Seventy.
Is this the first of its kind in this area?
HYAGRIV SIMHAN: It is to my knowledge. I’ve been practicing high-risk pregnancy for a long time and have a general awareness of what people are doing around the country and I think bringing this kind of approach to this condition is innovative.
What kind of an impact do you think it will have on health and wellness down the road for women in this program?
HYAGRIV SIMHAN: I think the potential impact is very high. Our short-term goals would be to reduce unnecessary hospitalizations and visits, which engages the population to be engaged at a lower expense. We also want to make sure that handoff happens so that cardiovascular disease prevention is maximized, which I think that in the longer term is the much higher yield; more important public health impact, like smoking cessation programs and how that’s come to the general awareness. I think we can do a lot better with young, healthy women in terms of cardiovascular disease prevention.
Is there anything I didn’t ask that you want to make sure people know?
HYAGRIV SIMHAN: One thing I didn’t say about the longer-term impact of diabetes when I was answering the question about gestational diabetes is we care about it in the short term outcomes for baby. However, women with gestational diabetes have a very high risk of Type 2 diabetes in the 10 years that follow pregnancy. Somewhere between half and two-thirds of women diagnosed with gestational diabetes will get diabetes within 10 years. Not 30 years later and not 10 percent of women. It’s a really high proportion in a relatively short period of time. This is a window into a woman’s health risk and it’s an opportunity for lifestyle modification, disease detection and prevention. As a corollary, another potential benefit of our diabetes monitoring program is to be able to take our engaged population of patients and do disease detection, prevention afterwards. We certainly care about mothers and babies during pregnancy in the short term, but in addition to that, the diabetes program has longer benefits for them and larger benefits for society.
How would you describe the attendance at the four to six week follow up visits nationally compared to the hypertension monitoring program?
HYAGRIV SIMHAN: One of the goals of the hypertension monitoring program is attendance at the postpartum visits. Routinely, an after pregnancy visit with a midwife or with OB/GYN is recommended for all pregnant women at four to six weeks postpartum. In general in the US, attendance at that visit is very low. In some populations as low as 25 or 30 percent, and 40 percent across the board. We found that in our population of postpartum hypertension remote monitoring we’ve had follow up rates higher than 90 percent. I think that’s a manifestation, a representation of an engaged population.
END OF INTERVIEW
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