Screen for Hypertensive Disorders During Every Prenatal Visit: USPSTF

The United States Preventive Services Task Force (USPSTF) is recommending routine blood-pressure screening for hypertensive disorders throughout pregnancy, with the experts concluding with “moderate certainty” that screening will result in a substantial net health benefit.

That B recommendation is consistent with the prior, 2017 USPSTF statement that recommends preeclampsia screening, but now broadens that to include screening for all hypertensive disorders. This includes chronic or preexisting hypertension, which is diagnosed before pregnancy or within the first 20 weeks of gestation, gestational hypertension (new-onset hypertension after 20 weeks of gestation), preeclampsia, and eclampsia.

“We're recommending that pregnant persons obtain a blood pressure measurement at every prenatal visit in order to identify as early as possible those individuals who do have a hypertensive disorder so they can move on to evidence-based management and surveillance,” Wanda K. Nicholson, MD, MPH (George Washington University, DC), a member of the task force, told TCTMD. “We know that this will help us have the healthiest moms and babies possible.”

The USPSTF continues to recommend aspirin after 12 weeks gestation as a preventive measure for people at high risk for preeclampsia, which is also a B recommendation as part of the 2017 statement.

The expanded recommendation, along with an updated evidence report and systematic review, several editorials, audio commentary, and a patient’s page, was published last week in JAMA and its family of journals.

Health Inequities Abound

Right now, hypertensive disorders of pregnancy are among the leading causes of maternal morbidity and mortality in the US, a problem that has been escalating over the past couple of decades. According to the USPSTF, hypertensive disorders, including preeclampsia, caused nearly 7% of pregnancy-related deaths in the US between 2014 and 2017.

“We do have a maternal mortality crisis in this country,” said Nicholson, “and much of the maternal deaths stem from hypertensive disorders of pregnancy. This is at the core of the maternal deaths that we are seeing across the country, and part of our goal in this recommendation statement, in addition to recommending blood pressure be measured at every visit, is really to call attention to this maternal health crisis.”

It's also a crisis that disproportionately affects Black and American Indian/Alaskan Native pregnant persons, said Nicholson. In the US, Black individuals have higher rates of maternal and infant morbidity and perinatal mortality than any other racial/ethnic groups. They are also at a higher risk of developing hypertensive disorders of pregnancy than other groups. Compared with white individuals, pregnancy-related mortality is significantly higher among Native American/Alaskan Native persons. Nicholson said these disparities make clear the need for more research, particularly with respect to interventions to address inequities of care at the level of policy, health systems, and clinical practice.

As part of the statement, the USPSTF notes there isn’t adequate evidence on whether any other screening methods, such as home blood-pressure monitoring, could reduce maternal and perinatal morbidity and mortality when compared with office-based visits. This is another area for future research since it might be possible to identify hypertensive disorders earlier, said Nicholson.

Other areas of research include the best approach to “detecting and mitigating” the consequences of hypertensive disorders that develop in the postpartum period. Nicholson said that in their review of the evidence, there was very limited research on screening in the postpartum period, something that is required, particularly to identify what screening intervals might be best to reduce morbidity and mortality in this period.  

In an editorial by Srilakshmi Mitta, MD (Warren Alpert Medical School of Brown University, Providence, RI), and colleagues, the group highlights the “profound disconnect between the public health urgency of the need to screen for hypertensive disorders of pregnancy and the pace of research.” In the past 25 years, they write, there’ve been just two randomized clinical trials in this field, the last being BUMP, which found no benefit of home blood-pressure monitoring.

In another editorial, Anne Denoble, MD, MSc, and Christian Pettker, MD (Yale University School of Medicine, New Haven, CT), point out that while the basic tools for screening can be “applied with skill and might,” addressing the larger maternal health crisis will require greater efforts at multiple levels, including national and local governments. 

In a subtle but notable change, the language of the updated recommendations refers to the more inclusive “pregnant persons” not “pregnant women.”