Screening for Hypertensive Disorders of Pregnancy in the US—A New Hypertensive Urgency

Maternal death is a tragedy in any setting. Unfortunately, the US has maternal mortality far higher than many other well-resourced nations.¹ Moreover, egregious disparities within the US population persist: Alaska Native, American Indian, and Black individuals experience maternal mortality rates 2 to 3 times those of White individuals, and rates among Hispanic individuals are at an all-time high.^2,3 The fact that approximately 80% of maternal deaths are preventable⁴ highlights the urgency and responsibility for all clinicians to ensure that pregnant-capable, pregnant, and postpartum individuals are screened, counseled, and treated for one of the leading contributors to maternal deaths: hypertensive disorders of pregnancy (HDP). In this context, the US Preventive Services Task Force (USPSTF) should be applauded for its updated recommendation statement and expansion of focus to the 2017 recommendation for screening for preeclampsia among pregnant persons.^5,6 Given the US’s abysmal track record in addressing maternal mortality, a new sense of “hypertensive urgency” is required: screening for and addressing HDP must be prioritized and addressed with a renewed focus by clinicians, policymakers, and the research community.

The USPSTF maintained its B recommendation,⁵ which was supported by an updated evidence report and systematic review,⁷ with an expanded scope to screen for all HDP, including gestational hypertension, preeclampsia, eclampsia, and chronic hypertension with superimposed preeclampsia or eclampsia. This extension of the screening scope beyond a sole focus on preeclampsia is timely and appropriate, as all HDP rates have increased since 1990⁴ and comprise a substantial contributor to maternal mortality and morbidity.⁴ It is important to note that pregnancy is not the only time when screening, counseling, and treatment should occur. All persons who have reproductive capacity and/or are planning pregnancy, along with those who are post partum, should be screened for hypertensive disorders, aligning the USPSTF with guidelines from the American College of Obstetricians and Gynecologists, the American College of Cardiology, and the American Heart Association.⁸

Screening for HDP can and should be within the purview of internists. Internal medicine physicians are the largest group of primary care clinicians and should be aware of the need to screen for HDP, as often they are the primary point of contact for these patients before, during, and after pregnancy—even when the pregnancy itself might be managed by obstetrical specialists. The public health urgency of HDP requires an all-hands-on-deck approach, wherein all health systems and clinicians should be held accountable for identifying and treating HDP. This is especially the case for racial and ethnic minoritized individuals who in addition to possessing higher rates of morbidity and mortality, face social, economic, and other barriers to accessing all health care,^2,3 and where the primary care internist may be the sole provider of health care.

Many clinicians lack adequate exposure to and training in medical conditions in pregnancy and subsequently do not feel knowledgeable or comfortable caring for these patients.⁹ Hypertensive disorders of pregnancy have long since been recognized as predictors for the development of hypertension, stroke, myocardial infarction, and heart failure¹⁰ later in life, which all solidly fall into the scope of practice for most primary care physicians. Given the remarkable influence on not just severe maternal morbidity and mortality, but also future health, the screening, counseling, and treatment of HDP should far precede the isolated moment of pregnancy.

Another critical theme raised in the current USPSTF recommendation⁵ is the profound disconnect between the public health urgency of the need to screen for HDP and the pace of research to address them. The 2017 USPSTF evidence review,¹¹ supporting the 2017 recommendation,⁶ highlighted the sole randomized clinical trial, which was 20 years old, comparing different screening strategies. Now, 6 years later, the new 2023 evidence review includes only 1 additional completed trial.⁷ The Blood Pressure Monitoring in High-Risk Pregnancy to Improve the Detection and Monitoring of Hypertension (BUMP) trial, which was performed in the UK, found that home blood pressure monitoring was not associated with improvement in any of the primary outcomes evaluated.¹² Where are the trials conducted in the US? Where are the trials on disparities in HDP? The stark paucity of research in HDP parallels the dearth of research inclusive of pregnant individuals more broadly and reflects the National Institutes of Health’s lack of focus on research in women’s health, with only 11% of funding dedicated to women’s health research across its 27 institutes and centers.¹³

Given profound and long-standing disparities, it is unsettling that virtually none of the evidence included in the 2023 USPSTF reports focuses on Alaskan Native, American Indian, Black, or Hispanic populations—the very groups who bear a disproportionate burden of illness and who would have the most to gain from the development and evaluation of new interventions. Undoubtedly, the research ecosystem needs a substantial boost and reorientation to ensure identification of new strategies (engaging communities, addressing social determinants), tools (risk assessment, telehealth, remote monitoring), and actionable data resources. One promising approach is the concept of data justice, which calls for collecting, analyzing, and disseminating data with a focus on community-driven needs and assets, and ensures that the resulting data will be used to empower community stakeholders to improve health.¹⁴ This need for data was incorporated into the Preventing Maternal Deaths Act of 2018, which will help in recognizing problem areas leading to the high morbidity and mortality and in identifying ways to intervene and make change. To be sure, dedicated, informed clinicians and a robust research ecosystem will be necessary but not sufficient to address this HDP urgency, particularly in the face of long-standing inequities.

Every dimension of access to high-quality, consistent care, ranging from insurance coverage, health literacy, and financial toxicity, to the experience of bias, racism, and distrust affects the entire health care delivery spectrum and disproportionately affects pregnant-capable, pregnant, and postpartum persons among racial and ethnic minoritized groups. The updated USPSTF recommendation⁵ identifies structural racism and interpersonal racism as critical contributors to disparities in healthy living environments, unstable housing, disproportionate stress, and lack of healthy food access, all of which create an ever-growing gap in equitable and unbiased care for the pregnant population. Internists, primary care physicians, and specialists all need to contribute to the mission for improvement in health before, during, and after pregnancy. Expanding medical education regarding inequities in care and pregnancy-related medical disorders is fundamental in reducing maternal mortality in the US. Educating all clinicians, through increased research and awareness, will enhance understanding and familiarity with the care of pregnant patients and provide valuable, effective, long-term care across the life course. However, policymakers must play an active role, investing in identifying and implementing novel and effective interventions that will improve pregnancy-related outcomes in high-risk populations.

Pregnancy is a window of opportunity to influence current and future life course, not just of the individual, but also of the fetus(es), other children, and family. Poor maternal health reflects inaction and reluctance as a nation to prioritize wellness and health for all. We cannot ignore the rising maternal morbidity and mortality rates and must recognize this public health crisis that is affecting us all. The onus is on all of us. To the scientific community, research should not be an afterthought for pregnant-capable and pregnant persons, because through research we can advance the clarity and implementation of the care recommendations. Finally, it is imperative that the medical community, especially internists, take more responsibility in caring for pregnant individuals’ immediate and long-term health: it takes a collective village, acting with purpose and urgency.

Corresponding Author: Melissa A. Simon, MD, MPH, Center for Health Equity Transformation, Northwestern University Feinberg School of Medicine, 625 N Michigan Ave, Ste 1100, Chicago, IL 60611 ([email protected]).

Published Online: September 19, 2023. doi:10.1001/jamainternmed.2023.4723

Conflict of Interest Disclosures: Dr Simon is a member of the Advisory Committee for Research on Women’s Health for the National Institutes of Health Office of Research on Women’s Health and a member of the Centers for Disease Control and Prevention Community Preventive Services Task Force, as well as a former member of the USPSTF from 2017 to 2020. Dr Gross reported grants from Johnson and Johnson and the National Comprehensive Cancer Network (through a grant to the National Comprehensive Cancer Network from AstraZeneca) and personal fees from Genentech. No other disclosures were reported.

Disclaimer: The views in this Editorial are those of the authors and should not be attributed to the Advisory Committee for Research on Women’s Health nor the National Institutes of Health Office of Research on Women’s Health.