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To describe clinician screening practices for prior hypertensive disorders of pregnancy, knowledge of future risks associated with hypertensive disorders of pregnancy, barriers and facilitators to referrals for cardiovascular disease risk evaluation in women with prior hypertensive disorders of pregnancy, and variation by clinician- and practice-level characteristics.We used data from Fall DocStyles 2020, a cross-sectional, web-based panel survey of currently practicing U.S. clinicians. Of 2,231 primary care physicians, obstetrician-gynecologists (ob-gyns), nurse practitioners, and physician assistants invited to participate, 67.3% (n=1,502) completed the survey. We calculated the prevalence of screening, knowledge of future risks, and barriers and facilitators to referrals, and assessed differences by clinician type using χ2 tests. We evaluated associations between clinician- and practice-level characteristics and not screening using a multivariable log-binomial model.Overall, 73.6% of clinicians screened patients for a history of hypertensive disorders of pregnancy; ob-gyns reported the highest rate of screening (94.8%). Overall, 24.8% of clinicians correctly identified all cardiovascular risks associated with hypertensive disorders of pregnancy listed in the survey. Lack of patient follow-through (51.5%) and patient refusal (33.6%) were the most frequently cited barriers to referral. More referral options (42.9%), patient education materials (36.2%), and professional guidelines (34.1%) were the most frequently cited resources needed to facilitate referrals. In the multivariable model, primary care physicians and nurse practitioners, as well as physician assistants, were more likely than ob-gyns to report not screening (adjusted prevalence ratio 5.54, 95% CI 3.24-9.50, and adjusted prevalence ratio 7.42, 95% CI 4.27-12.88, respectively). Clinicians seeing fewer than 80 patients per week (adjusted prevalence ratio 1.81, 95% CI 1.43-2.28) were more likely to not screen relative to those seeing 110 or more patients per week.Three quarters of clinicians reported screening for a history of hypertensive disorders of pregnancy; however, only one out of four clinicians correctly identified all of the cardiovascular risks associated with hypertensive disorders of pregnancy listed in the survey.

Background Clinical practices can use telemedicine and other strategies (e.g., self-measured blood pressure [SMBP]) for remote monitoring of hypertension to promote control while decreasing risk of exposure to SARS-CoV-2, the virus that causes COVID-19. Methods The DocStyles survey collected data from primary care providers (PCPs), obstetricians-gynecologists (OB/GYNs), and nurse practitioners/physician assistants (NP/PAs) in fall 2020 (n = 1,502). We investigated clinical practice changes for monitoring hypertension that were implemented early in the COVID-19 pandemic and examined differences by clinician and practice characteristics (P < 0.05). Results Overall, 369 (24.6%) of clinicians reported their clinical practices made no changes in monitoring hypertension early in the pandemic, 884 (58.9%) advised patients to monitor blood pressure at home or a pharmacy, 699 (46.5%) implemented or increased use of telemedicine for blood pressure monitoring visits, and 545 (36.3%) reduced the frequency of office visits for blood pressure monitoring. Compared with NP/PAs, PCPs were more likely to advise SMBP monitoring (adjusted prevalence ratios [aPR] 1.28, 95% confidence intervals [CI] 1.11–1.47), implement or increase use of telemedicine (aPR 1.23, 95% CI 1.04–1.46), and reduce the frequency of office visits (aPR 1.37, 95% CI 1.11–1.70) for blood pressure monitoring, and less likely to report making no practice changes (aPR 0.63, 95% CI 0.51–0.77). Conclusions We noted variation in clinical practice changes by clinician type and practice characteristics. Clinical practices may need additional support and resources to fully maximize telemedicine and other strategies for remote monitoring of hypertension during pandemics and other emergencies that can disrupt routine health care.

Previous efforts to examine severe maternal morbidity (SMM) in the US have focused on delivery hospitalizations. Little is known about de novo SMM that occurs after delivery discharge.To investigate the incidence, timing, factors, and maternal characteristics associated with de novo SMM after delivery discharge among women in the US.In this retrospective cohort study, data from the IBM MarketScan Multi-State Medicaid database and the IBM MarketScan Commercial Claims and Encounters database were used to construct a sample of women aged 15 to 44 years who delivered between January 1, 2010, and September 30, 2014. Severe maternal morbidity was reported by the timing of diagnosis, and the associated maternal characteristics were examined. Women in the Medicaid and commercial insurance sample were classified into 3 distinct outcome groups: (1) those without any SMM during the delivery hospitalization and the postdelivery period (reference group), (2) those who exhibited at least 1 factor associated with SMM during the delivery hospitalization, and (3) those who exhibited any factor associated with de novo SMM after delivery discharge (defined as SMM that was first diagnosed in the inpatient setting during the 6 weeks [or 42 days] after discharge from the delivery hospitalization, conditional on no factor associated with SMM being identified during delivery). Data were analyzed from February to July 2020.Timing of SMM diagnosis.Women with SMM were identified using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification for the 21 factors associated with SMM that were developed by the Centers for Disease Control and Prevention.A total of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014 were identified; of those, 809 377 women (30.3%) had Medicaid insurance (30.3%; mean [SD] age, 25.6 [5.5] years; 51.1% White), and 1 857 948 women (69.7%; mean [SD] age, 30.6 [5.4] years; 36.4% from the southern region of the US) had commercial insurance. Among those with Medicaid insurance, 17 584 women (2.2%) experienced SMM during the delivery hospitalization, and 3265 women (0.4%) experienced de novo SMM after delivery discharge. Among those with commercial insurance, 32 079 women (1.7%) experienced SMM during the delivery hospitalization, and 5275 women (0.3%) experienced de novo SMM after hospital discharge. A total of 5275 SMM cases (14.1%) and 3265 SMM cases (15.7%) among women with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after hospital discharge; of those, 3993 cases (75.7%) in the commercial insurance cohort and 2399 cases (73.5%) in the Medicaid cohort were identified in the first 2 weeks after discharge. The most common factors associated with SMM varied based on the timing of diagnosis. In the Medicaid population, non-Hispanic Black women (adjusted odds ratio [aOR], 1.53; 95% CI, 1.48-1.58), Hispanic women (aOR, 1.46; 95% CI, 1.37-1.57), and women of other races or ethnicities (aOR, 1.40; 95% CI, 1.33-1.47) had higher rates of SMM during delivery hospitalization than non-Hispanic White women; however, only the disparity between Black and White women (aOR, 1.69; 95% CI, 1.57-1.81) persisted into the postdischarge period.In this study, 15.7% of SMM cases in the Medicaid cohort and 14.1% of SMM cases in the commercial insurance cohort first occurred after the delivery hospitalization, with notable disparities in factors and maternal characteristics associated with the development of SMM. These findings suggest a need to expand the focus of SMM assessment to the postdelivery discharge period.

Objective Develop a core outcome set of international consensus definitions for severe maternal morbidities. Design Electronic Delphi study. Setting International. Population Eight expert panels. Methods All 13 high-income countries represented in the International Network of Obstetric Surveillance Systems (INOSS) nominated five experts per condition of morbidity, who submitted possible definitions. From these suggestions, a steering committee distilled critical components: eclampsia: 23, amniotic fluid embolism: 15, pregnancy-related hysterectomy: 11, severe primary postpartum haemorrhage: 19, uterine rupture: 20, abnormally invasive placentation: 12, spontaneous haemoperitoneum in pregnancy: 16, and cardiac arrest in pregnancy: 10. These components were assessed by the expert panel using a 5-point Likert scale, following which a framework for an encompassing definition was constructed. Possible definitions were evaluated in rounds until a rate of agreement of more than 70% was reached. Expert commentaries were used in each round to improve definitions. Main outcome measures Definitions with a rate of agreement of more than 70%. Results The invitation to participate in one or more of eight Delphi processes was accepted by 103 experts from 13 high-income countries. Consensus definitions were developed for all of the conditions. Conclusion Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process. These should be used in national registrations and international studies, and should be taken up by the Core Outcomes in Women's and Newborn Health initiative. Tweetable abstract Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process.

Background: The present study focuses on the nature of the population's financial decisions carried out under the personal financial planning process by people. Method: The methodological basis of the study is constituted by such methods of scientific research as statistical monitoring and comparative analysis, synthesis and forecasting. The authors have presented a model of consumer choice. Findings: The authors have analyzed the financial public decisions made in the context of economic instability; personal finance structure and consumer sentiment level dynamics have been covered; Russian citizens' income differentiation trends have been shown. The main results of the study provide insights into the tendencies in the economic behavior of citizens that can be characteristic of the population of any state at times of macroeconomic parameters volatility. In particular, the authors identified comparative structure of the attracted credit resources and the citizens' savings accumulated in commercial banks; it shows the ratio of savings and the amount of mandatory expenditures of the population; the Russians' consumer sentiment index dynamics has been traced; the population has been arranged by quintile groups on the basis of the existent income differentiation trends in the Russian society. Key findings of the study are identification of very weak signs of the population's adaptation to the economic and the geopolitical situation volatility, which is reflected in the discernible consumption bursts. Improvements: The authors have proved that the motivation for the population's financial decisions and the socio-economic stratification in Russia are crucially influenced by such factors as the loss of a source of income (job) and the devaluation shocks.

Background: Mortality rates as high as 20% have been reported for pregnant patients with intracerebral hemorrhage (ICH). The aim of this study is to describe the risk factors, management and outcomes of pregnant compared to non-pregnant patients with ICH in the Get With The Guidelines (GWTG) Stroke Registry. Methods: Using medical history or ICD-9 codes, we identified 178 pregnant and 4817 non-pregnant female patients aged 18-44 with ICH in GWTG from 2008-2013. Differences in patient and care characteristics were compared by Chi-square tests for categorical variables and Wilcoxon Rank-Sum tests for continuous variables. Stratified logistic regression assessed the effect of pregnancy on outcomes conditional on age and adjusted for patient and hospital characteristics. Results: Pregnant ICH patients were younger, had fewer preexisting stroke risk factors and used fewer associated medications. Median initial blood pressures, initial neurologic exam findings and measures of guideline-based care were similar between groups (Table). Stroke onset did not occur in a healthcare setting for >85% of all patients, but pregnant patients took longer to arrive (median 268 vs. 186 min), used EMS less often (29% vs. 39%) and went to larger hospitals with higher annual ICH admissions than non-pregnant patients. Risk adjusted odds of in-hospital death in pregnant women were about half that of non-pregnant women (aOR 0.57, 95% CI 0.34-0.94), but length of stay >6 days (aOR 1.39, 95% CI 0.86-2.27), independent ambulation at discharge (aOR 1.12, 95% CI 0.81-1.54) and discharge to home (aOR 1.10, 95% CI 0.81-1.51) outcomes were similar. Conclusions: Pregnant women with ICH are younger and healthier than their non-pregnant counterparts but have similar presenting symptoms. Despite later arrival times, in-hospital mortality is lower, suggesting differences in underlying disease pathophysiology.

Background: Subarachnoid hemorrhage (SAH) accounts for up to 4.1% of all pregnancy-related in-hospital deaths, but is less often aneurysmal and is associated with better short term outcomes than in non-pregnant patients. We sought to describe the risk factors, management and outcomes of pregnant vs. non-pregnant patients with SAH in the Get With The Guidelines (GWTG) Stroke Registry. Methods: Using medical history or ICD-9 codes, we identified 152 pregnant and 5745 non-pregnant SAH female patients aged 18-44 with SAH in GWTG from 2008-2013. Differences in characteristics were compared by Chi-square tests for categorical and Wilcoxon Rank-Sum tests for continuous variables. Stratified logistic regression assessed the effect of pregnancy on outcomes conditional on age and adjusted for patient and hospital characteristics. Results: Pregnant SAH patients were younger, more often black and insured with Medicaid. They had higher initial blood pressure (BP) and were less likely to report prior hypertension. Arrival delays from stroke onset were common in both groups (median 340 vs. 277 min), but pregnant SAH patients were more often already hospitalized at stroke onset (16% vs. 10%). Fewer pregnant vs. non-pregnant SAH patients had initial neurologic exam findings recorded (Table). Pregnant SAH patients had lower in-hospital death than non-pregnant patients (aOR 0.17, 95% CI 0.06-0.45) and were more likely at discharge to ambulate independently (aOR 2.40, 95% CI 1.56-3.69) and return home (aOR 2.60, 95% CI 1.67-4.06). Conclusions: Several differences exist between pregnant and non-pregnant women with SAH. Many present with BP well below the threshold for hypertensive disorders of pregnancy, making prompt recognition and prevention of brain hemorrhage challenging. Overall, pregnancy-related SAH is associated with less morbidity and mortality than non-pregnancy related disease.

Background: Ischemic Stroke (IS) is a rare but serious event during pregnancy or the postpartum period. We compared the characteristics and outcomes of pregnant vs. non-pregnant women diagnosed with IS in the Get With The Guidelines Stroke Registry. Methods: We identified 24641 female patients aged 18-44 with IS, based on medical history or ICD-9 codes, from 2008-2013. Patient and hospital categorical variables were compared by Chi-square and continuous variables by Wilcoxon Rank-Sum. Stratified logistic regression assessed the effect of pregnancy on outcomes conditional on age and adjusted for patient and hospital characteristics. Results: There were 338 (1.4%) pregnant IS patients. Compared to non-pregnant patients, pregnant patients had fewer traditional stroke risk factors, were less often black, and were more likely to be insured by Medicaid, in a healthcare setting at stroke onset, and admitted to a stroke center. Both groups had similar initial mild stroke severity and exam findings most notable for weakness (Table). Discharge outcomes of in-hospital death (aOR 0.70, 95% CI 0.33-1.50), discharge to home (aOR 1.04, 95% CI 0.81-1.34), independent ambulation (aOR 1.03, 95% CI 0.79-1.34) or length of stay >4 days (aOR 1.27, 95% CI 0.96-1.68) did not differ between groups. Of the 145 cases where pregnancy stage was coded, 76 (52.4%) occurred postpartum and 65 (44.8%) antepartum, with no difference in discharge outcomes. Women with postpartum compared with antepartum IS were more likely to have hypertension, use antihypertensives pre-stroke, and have higher median initial post-stroke blood pressure. Conclusions: Pregnancy-related IS is uncommon and occurs in women with few traditional stroke risk factors, often within 6 weeks postpartum. Despite these differences, short term outcomes after stroke are similar to non-pregnant women. Further research is needed to determine if pregnancy, itself, independently contributes to stroke risk.

Background: Pregnancy and recent cesarean delivery are thought to pose unacceptable complication risks from IV thrombolysis (tPA), and most pregnant or recently postpartum women with ischemic stroke (IS) do not receive IV tPA. We sought to determine the frequency of IV tPA use and short term outcomes among pregnant vs. non-pregnant women with IS in the Get With the Guidelines Stroke Registry. Methods: Pregnant or recently postpartum ( Results: Pregnant patients were less likely to receive IV tPA than non-pregnant patients (15/338 (4.4%) vs. 1913/24303 (7.9%), p = 0.03). The primary reasons documented for non-treatment in the 0-3 hour timeframe were pregnancy itself (58% vs. 0%) and recent surgery (47% vs. 12%). Other less commonly noted reasons were stroke symptoms too mild (16% vs. 31%) or rapid improvement (13% vs. 32%). There were no differences in major complications between groups (Table). Discharge outcomes between groups were comparable, with low rates of in-hospital mortality (0-2%) and high rates of home discharge (60-72%). Only the proportion with length of stay > 4 days differed, and was more frequent among pregnant patients (Table). Conclusions: Pregnant patients with IS undergo IV thrombolysis infrequently; less often than non-pregnant patients of childbearing age. Despite the rare use, the short term outcomes and complication rates in these pregnant patients generally appear to be favorable and similar to non-pregnant women. As the data are underpowered to show true differences between the groups, larger studies are warranted to study the efficacy and safety of thrombolysis in pregnancy.

Background: Although alarmingly increasing trends of stroke in pregnancy has been reported in the US, few studies have investigated clinical outcomes, including outcomes of IV alteplase (tPA) treatment among pregnant women. Methods: Data was abstracted from the Nationwide Inpatient Sample, an all-payer inpatient care database. We identified pregnancy-related hospitalizations from 2005-2010 by ICD-9-CM diagnostic codes. We extracted diagnoses of acute ischemic stroke (AIS), intracerebral (ICH) and subarachnoid (SAH) hemorrhage, transient ischemic attack, cerebral venous thrombosis (CVT), unspecified, and other pregnancy-related complications. We also identified pregnant women with AIS who received IV tPA. Clinical outcomes included length of stay (LOS), discharge disposition, and in-hospital mortality. Results: An estimated 18,392 pregnant women were diagnosed with stroke from 2005-2010. CVT (26.8%) and hemorrhagic (ICH and SAH) stroke (22.8%) were the most common types of stroke, with about 20% of all stroke reported as unspecified in 2010. Mean LOS ranged from 6.5-7.2 days; linear regression did not reveal significant trends in LOS over time. The most common pregnancy-related stroke risk factors included hypertension (30.2%) and pre-eclampsia (13.4%). Decreasing trend of discharge home (from 78.3 to 72.6%, p=0.09) and increasing mortality rate (from 1.8% to 4.0% p for linear trend=0.02) were observed from 2005 to 2010. Of the estimated 70 pregnant AIS patients treated with IV tPA, LOS ranged 4-28 days; 78.6% were discharged home, 14.3% to skilled nursing facility, and 7.1% died. Conclusions: Stroke remains a serious complication in pregnancy, and mortality is increasing. Usage of tPA for AIS during pregnancy is minimal, with increased mortality compared to all strokes in pregnancy. Research efforts are needed to improve stroke outcomes during pregnancy.

Introduction: The 2010 Dietary Guidelines recommend Americans reduce sodium intake and choose foods that contain potassium to decrease the risk of hypertension and subsequent heart disease and stroke. Limited data exist on the proportion of U.S. adults who meet the 2010 Dietary Guidelines for Americans for sodium and potassium. Hypothesis: We hypothesized that the majority of U.S. adults do not meet the 2010 Dietary Guidelines for sodium and potassium. Methods: We used 24-hour dietary recalls and other data from 12,581 non-institutionalized adults aged > 20 years who participated in the National Health and Nutrition Examination Survey in 2003–2008. We estimated the distributions of usual daily sodium and potassium intakes by sociodemographic and health characteristics relative to the 2010 Dietary Guidelines. Health characteristics included hypertension (use of anti-hypertensive medications, systolic blood pressure > 140 mm Hg or diastolic blood pressure > 90 mm Hg), diagnosed (self report) or undiagnosed diabetes (fasting plasma glucose > 126 mg/dL or glycohemoglobin > 6.5%), and chronic kidney disease (defined by estimated glomerular filtration rate 2 or urine albumin-creatinine ratio > 30 mg/g). Estimates of usual sodium and potassium intake were adjusted for within-individual, day-to-day variation using measurement error models (Software for Intake Distribution Estimation) with two-24 hour diet recalls on 89.6% of our sample. Standard errors and ninety-five percent confidence intervals were assessed using jack-knife replicate weights. Results: Overall, 99.4% (95% confidence interval [CI], 99.3%, 99.5%) and 90.7% (89.6%, 91.8%) of U.S. adults consumed >1500 mg and > 2300 mg sodium daily, respectively. Among U.S. adults recommended to reduce sodium to 1500 mg daily (i.e., African-Americans, age >51 years, or persons with hypertension, diabetes, or chronic kidney disease), 98.8% (98.4%, 99.2%) consumed >1500 mg daily and 60.4% consumed more than double the recommendation, >3000 mg daily. Regardless of sex, age, race-ethnicity, income, education, body mass index, hypertension, diabetes, or chronic kidney disease more than 84% of adults consumed sodium in excess of guidelines. Overall, less than 2% of U.S. adults and ∼5% of U.S. men consumed > 4700 mg potassium daily, i.e., meeting 2010 Dietary Guidelines for potassium. Conclusions: Limitations of our analyses include estimation of nutrient intake from 24-hour diet recalls and inability to account for salt added at the table or from supplements, potentially resulting in an underestimation of sodium and potassium intake. In conclusion, most U.S. adults consume too much sodium and too little potassium.

Introduction: Evidence from randomized controlled trials demonstrates higher sodium and/or lower potassium intake increase blood pressure and the risk of hypertension. However, the relationship between sodium, potassium and blood pressure has not been examined using nationally representative sample and estimated usual intakes of these nutrients. Hypothesis: We hypothesized that usual sodium and potassium intake have opposing effects on blood pressure and a higher sodium-to-potassium ratio is associated with elevated blood pressure and hypertension. Methods: We analyzed data on 12,854 participants aged 20 years and older from the 2003-2008 National Health and Nutrition Examination Surveys. We estimated the usual intakes of sodium and potassium from the diet accounting for measurement error. Mean blood pressure was calculated from up to three readings on each subject and hypertension included both diagnosed and undiagnosed hypertension. We used multivariable linear regression to examine the associations between intakes of sodium, potassium and their ratio with systolic and diastolic blood pressure, and logistic regression for associations with hypertension. Results: The average estimated usual intakes of sodium and potassium were 3465 and 2741 mg/d, respectively. The average sodium-to-potassium ratio was 1.39; higher ratios were observed among males, younger and non-Hispanic black participants. After adjustment for potential confounders, usual intakes of sodium, potassium and their ratio were significantly associated with systolic blood pressure, with an increase of 1.08 mm Hg (95% confidence interval (CI): 0.30 – 1.86) and a decrease of 1.47 mmHg (95% CI: -2.31, -0.63) for every 1000 mg/d increase in sodium and potassium intake, respectively, and an increase of 2.80 mmHg (95% CI: 0.90 - 4.70) for every unit increase in sodium-to-potassium ratio. No association was found for diastolic blood pressure. The adjusted odds ratio (OR) comparing the highest and lowest quartiles of usual sodium or potassium intakes were 1.63 (95% CI: 1.14 - 2.34) and 0.61 (95% CI: 0.45 - 0.82), respectively, for risk of hypertension. For sodium-to-potassium ratio, the adjusted OR was 1.49 (95% CI: 1.17 - 1.89). The patterns of association were largely consistent across age, gender, race/ethnicity, body mass index, and education subgroups. Conclusions: In conclusion, our results indicated higher sodium and lower potassium intakes were associated with increased systolic blood pressure and risk for hypertension. The combined effect of sodium and potassium might play a central role in the pathogenesis of hypertension. The results further confirm that reducing sodium and increasing potassium intakes concurrently may have important implications in the prevention of hypertension, and hence, of cardiovascular disease.