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Hypertensive Disorders of Pregnancy (HDP) and Self-Monitoring Blood Pressure Education (SMBP)

Project Funded by: Michigan Health Endowment Fund

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Background
Intervention Goals
HTN Infographic & Action Plan
Implementation Workflow
Hypertensive Disorders of Pregnancy (HDP) Scope of Disease
CDC Hear Her Campaign/Kick Counts
Preeclampsia Risk Factors & Long-Term Maternal Complications
Improving Prevention and Management of HTN During & After Pregnancy
Self-Monitoring Blood Pressure (SMBP) Monitoring Education
Device Calibration Test
Resources
SMBP Practice Session

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Maternal Mortality Affects Too Many Mothers

669

^{In 2023, 669 women died of maternal causes in the United States*}

80%

^{More than 80% of pregnancy-related deaths could be prevented}

3-4X

^{Black women are 3-4 times more likely to die than white women}

*Source: Maternal Mortality Rates in the U.S., 2025, CDC.gov

Data are from the National Vital Statistics System

Talking Points:

This data became available early this month, February 2025
In 2022, 817 women died of maternal causes in the U.S., so it’s come down a little, but nowhere near where we need to be. It’s unacceptable and one maternal death is too many!
American Indian, Alaska Native, Black, Native Hawaiian, and Pacific Islander women are 2-3 times more likely to die of pregnancy-related causes than White women.
We know that racial disparities exist and due to structural racism, Black birthing persons are 3-4 times more likely to die from a pregnancy-related complication.
Other factors that contribute to disparities include variation in quality healthcare and underlying chronic conditions. Social determinants of health prevent many people from racial and ethnic minority groups from having fair opportunities for economic, physical, and emotional health.
Every pregnancy-related death is tragic, especially because more than 80% of pregnancy-related deaths in the U.S. are preventable.

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Maternal mortality rate, by race and Hispanic origin:�United States, 2022 and 2023

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Challenges in Addressing Maternal Mortality and HDP:

Delays in identifying, seeking, reaching, and receiving timely quality care is one of the most complex maternal health problems to resolve.
Delays account for many women reaching available expert care late and when in worse clinical condition.

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Intervention Goals

Empower participants through

Education (warning signs, risk factors, understanding disease, self-care)
Action planning
Skill building—for SMBP at home
Connection to resources
Ongoing support

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Hypertension Basics

Blood pressure (BP) is the force of your blood pushing against the walls of your arteries. It is measured in millimeters of mercury (mm HG) and recorded as two numbers:

Systolic pressure (the top number): the pressure when the heart beats and pumps blood.
Diastolic pressure (the bottom number): the pressure when the heart is at rest between beats.

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What concerns you most about high blood pressure?

What is most important to you about managing your high blood pressure?

Choose 1-3 Goals that you can do over the next two weeks:

Some things that may stop me from completing my goals are:

If this happens, I will:

My support people are:

How sure are you that you can follow this plan?

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Can you write me a prescription for a blood pressure monitor/cuff?
Should I start taking a daily low-dose aspirin (75-100mg) between 12 and 28 weeks of my pregnancy to prevent preeclampsia?
When should I report my readings to you and what is the best way to report them?
What is a healthy blood pressure for me?
If my reading is higher than this, when should I call your office?
When should I go to the emergency room?
What symptoms could mean I am having problems with my blood pressure?
What should I do if I’m having them?

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Workflow

*Repeat infographic education postpartum.

**If at any point the client develops HDP, restart the intervention at the Positive Branch.

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Why is Addressing HDP Important?

Nationally, from 2017-2019:

HDP was the cause of 7% of pregnancy-related deaths
More than 80% of all pregnancy-related deaths were preventable

In Michigan, from 2016-2020:

HDP was the 4th leading cause of pregnancy-related deaths (8.5%)
74.5% of all pregnancy-related deaths were determined to be preventable

National Data: CDC Newsroom. Four in 5 pregnancy-related deaths in the U.S. are preventable. 2022. https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html#print

Talking Points:

We know that hypertension in pregnancy threatens both mother and baby.
Notable health disparities exist among different racial and ethnic groups. For instance, non-Hispanic Black (20.9%) and American Indian/Alaska Native (16.4%) women have the highest prevalence of hypertension during delivery hospitalization.⁴ The prevalence of hypertension in pregnancy is also higher for women who are ≥ 35 years of age, live in the South and Midwest, live in rural counties, or live in areas with the lowest median household income. These disparities likely stem from underlying factors, such as health care access and quality; availability of nutritious, affordable food and safe places to be physically active; and structural racism, including systemic racial and gender bias within the health care system.
Pregnancy-related deaths in the United States during 2017–2019 caused by (per CDC):

Mental Health Conditions [including deaths to suicide and substance use disorder] (23%)
Hemorrhage (14%)
Cardiac and coronary conditions (13%)
Infection (9%)
Thrombotic embolism (9%)
Cardiomyopathy (9%)
HDP (7%)

Top causes of pregnancy-related death in Michigan 2016-2020:

Infection (14.2%)
Thrombotic Embolism (12.3%)
Substance Use Disorder (11.3%)
HDP (8.5%) – tied w/ CVD conditions
Cardiovascular Conditions (8.5%)
Hemorrhage (7.5%)
Mental Health Conditions (6.6%)
Homicide (6.6%)

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HDP Conditions

Chronic hypertension

Gestational hypertension

Preeclampsia

Preeclampsia with severe features

Eclampsia

Chronic hypertension w/ superimposed preeclampsia

HELLP

Talking Points:

Now, lets learn more about hypertension and pregnancy - It is complicated, with confusing terminology
It can happen to any woman, in any pregnancy
The earlier in pregnancy a HTN disorder is diagnosed, the more severe it usually becomes
Preeclampsia and other hypertensive disorders of pregnancy can be devastating diseases, made worse by delays in diagnosis or management, seriously impacting or even killing both women and their babies before, during or after birth.
Thousands of women and babies get very sick each year from a dangerous condition called preeclampsia, a life-threatening hypertensive disorder that occurs only during pregnancy and the postpartum period. Preeclampsia and related disorders such as gestational hypertension, HELLP syndrome, and eclampsia are most often characterized by a rapid rise in blood pressure that can lead to seizure, stroke, multiple organ failure, and even death of the mother and/or baby.

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Talking Points:

Nice visual – how the body, blood pressure and lab values change – and how HDPs take over the body and affects and can damage many different organs.
So this is why we educate them on the warning signs and are asking them to do SMBP outside of the clinical setting – at home
Chronic hypertension – diagnosed before pregnancy and treated with medication
Gestational hypertension:

Blood pressure becomes high for the first time after 20 weeks gestation of pregnancy (typically after 37 weeks)
Usually resolves within 6 weeks postpartum - after delivery

Preeclampsia: Usually begins after 20 weeks of pregnancy and up to 6 weeks post-partum/after birth (called post-partum preeclampsia)
Eclampsia (e-CLAMP-si-a) is a very serious complication of preeclampsia characterized by one or more seizures during pregnancy or in the post-partum period. In the developed world, eclampsia is rare and usually treatable if appropriate intervention is promptly sought. Left untreated, eclamptic seizures can result in coma, brain damage, and possibly maternal or infant death.
HELLP syndrome is one of the most severe forms of preeclampsia and occurs in 5-12% of preeclamptic patients. It can lead to substantial injury to the mother’s liver, a breakdown of her red blood cells and lowered platelet count. HELLP stands for: hemolysis, elevated liver enzymes, and lowered platelets. HELLP syndrome may initially be mistaken for the flu or gallbladder problems, because the pains may feel similar, and it can occur before the classic symptoms of preeclampsia appear.

The most important thing to remember with HELLP syndrome and preeclampsia is to listen to your body. If you don't feel right or have any of the symptoms, contact your healthcare professional immediately.

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Preeclampsia

Affects both the mother and the unborn baby.
A rapidly progressive condition characterized by high blood pressure and usually the presence of high levels of protein in the urine OR the new development of platelets, trouble with the kidneys or liver, fluid in the lungs, or signs of brain trouble such as seizures and/or visual disturbances.
It can happen after the 20th week of pregnancy or up to 6 weeks after birth.
Early recognition of preeclampsia signs and symptoms can save a person’s life!

Talking Points:

Most women with preeclampsia will deliver healthy babies and fully recover. However, some women will experience complications, several of which may be life-threatening to mother and/or baby. A woman’s condition can progress to severe preeclampsia very quickly. The rate of preeclampsia in the US has increased 25% in the last two decades and is a leading cause of maternal and infant illness and death.
Placenta – a new organ with pregnancy - starts in the placenta and is dysfunction in in the balance between the mom and the baby. Pathophysiology: Abnormal placental implantation; low level of placental growth factor, genetic predisposition; immunologic phenomena; vascular endothelial damage & oxidative stress
Underlying etiology is not well understood and it’s on the rise
According to guidelines released by the American College of Obstetricians and Gynecologists, the diagnosis of preeclampsia no longer requires the detection of high levels of protein in the urine (proteinuria). Evidence shows organ problems with the kidneys and liver can occur without signs of protein, and that the amount of protein in the urine does not predict how severely the disease will progress. Prior to these new guidelines, most healthcare providers traditionally adhered to a rigid diagnosis of preeclampsia based on blood pressure and protein in the urine.

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Signs & Symptoms

https://preeclampsia.org/signs-and-symptoms

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Baby’s movement stopping or slowing during pregnancy

Visit: Home - Count the Kicks (https://countthekicks.org)

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Hear Her Campaign Goals

Increase awareness of serious pregnancy-related complications and their warning signs.
Empower people who are pregnant and postpartum to speak up and raise concerns.
Teach people to share recent pregnancy history during each medical care visit for up to one year after being pregnant.
Encourage support systems to engage in important conversations.
Provide tools for pregnant and postpartum people, and healthcare professionals to better engage in life-saving conversations.

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Women know their bodies best and can often tell when something is not right.

Listening and taking the concerns of pregnant and recently pregnant women seriously is a simple, yet powerful action to prevent pregnant-related deaths.

Timely treatment and quality care can prevent many pregnancy-related deaths.

Partners, friends, and family are important advocates to make sure any health concern is appropriately addressed by a healthcare provider.

Everyone has a role to play in supporting moms and preventing pregnancy-related deaths.

Key Messages:

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Risk Factors for Preeclampsia

Looked at 78 different risk factors.
Some risk factors are things that people can possibly change like weight, blood sugar, or blood pressure prior to pregnancy.
Others, like family history or ethnicity, cannot be changed.
Unfortunately, even patients with no risk factors may still develop preeclampsia.
Overall, weight and blood sugar issues seemed to have the highest relationship to overall risk of preeclampsia.
More research needs to be done!

Source: A large study published in BJOG International Journal of Obstetrics and Gynaecology in January 2024

Talking Points:

Some risk factors are things that patients can possibly change like weight, blood sugar, or blood pressure prior to pregnancy. Others, like family history or ethnicity, cannot be changed. Unfortunately, even patients with no risk factors may still develop preeclampsia.
A recent panel of research experts conducted a large study called Risk factors for pre-eclampsia in clinical practice guidelines: Comparison with the evidence published in BJOG International Journal of Obstetrics and Gynaecology to look at 78 different risk factors that have been reported to contribute to the chance of getting preeclampsia. These factors came from clinical practice guidelines from 17 obstetric organizations from around the globe (like the American College of Obstetrics and Gynecology here in the United States or the Society of Obstetricians and Gynaecologists of Canada). A few key findings arose from the study:
Obesity (defined as a body mass index greater than 30 kg/m²) was the only risk factor that had a “definite” association with preeclampsia based on “high” quality evidence. Overall, weight and blood sugar issues seemed to have the highest relationship to overall risk of preeclampsia.
Many risk factors fell into the “probable” association with preeclampsia. Key factors like maternal age, going into pregnancy with high or somewhat high blood pressure readings, certain ethnicities, and chronic health conditions made up the majority of this “probable” group.
The study identified a few new risk factors that had “definite” or “probable” associations with preeclampsia, including severe anemia, being pre-hypertensive, and having had a prior stillbirth. These risk factors may be added to clinical care guidelines in the future.
Few risk factors had “high” or “moderate” quality of evidence. This speaks to the continuing need for more research on the relationship between individual risk factors and preeclampsia.

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Some key findings from the study:

Obesity (defined as a body mass index greater than 30 kg/m²) was the only risk factor that had a “definite” association with preeclampsia based on “high” quality evidence. Overall, weight and blood sugar issues seemed to have the highest relationship to overall risk of preeclampsia.
Many risk factors fell into the “probable” association with preeclampsia. Key factors like maternal age, going into pregnancy with high or somewhat high blood pressure readings, certain ethnicities, and chronic health conditions made up the majority of this “probable” group.
The study identified a few new risk factors that had “definite” or “probable” associations with preeclampsia, including severe anemia, being pre-hypertensive, and having had a prior stillbirth.

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Long-Term Maternal Complications

3 to 4 times the risk of high blood pressure

Double the risk for heart disease & stroke

Increased risk of developing diabetes

Talking Points:

For women who had preeclampsia and delivered preterm, had low-birthweight babies, or suffered from severe preeclampsia more than once, the risk of heart disease can be even higher. While still unknown whether the risk is caused by preeclampsia or if the woman was already predisposed, these risks first emerge in the years following a complicated pregnancy.
Although this may seem daunting, ample research shows that there are many ways for women to protect their heart health and that of their families! This research does not mean you will definitely develop heart problems if you had preeclampsia, but for some women pregnancy can serve as an early warning sign for future heart disease.
This kind of “heads up” gives you an opportunity to make changes now for a healthier tomorrow – and reap the benefits today, too!

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Improving Prevention and Management of Hypertension During & After Pregnancy

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Low-dose aspirin for certain pregnant women at higher risk of preeclampsia

Started between 12 and 28 weeks of gestation

Antihypertensive medications

Magnesium sulfate can prevent seizures and is used for severe preeclampsia

Talking Points:

Baby aspirin = 81mg
Accurate blood pressure measurement is important for diagnosing, classifying, and treating hypertensive disorders of pregnancy.
It is not the role of the Home Visitor/CHW to prescribe aspirin/medications, but it’s important to know how your clients are managing hypertensive disorders of pregnancy.
Antihypertensive therapy in the setting of hypertensive disorders of pregnancy should focus on the use of safe and effective medications specific to this population.
What are some question(s) you ask your clients about their medications? (prompt if needed, about barriers such as cost, transportation to get medicines, side effects…
What does What does expectant management look like for your pregnant mom/family unit?
How can we help to support them and their families during this more intense medical time?

Delivery:

Preeclampsia without severe features or gestational HTN: delivery >37 weeks

34-36 weeks – shared decision on delivery, expectant management

Preeclampsia with severe features: delivery >34 weeks

Less than 34 weeks maternal or fetal condition is unstable

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Low-Dose Aspirin �(75-100 mg)

Pregnant individuals at high-risk of preeclampsia with one or more of the following risk factors:

History of preeclampsia
Multifetal gestation
Chronic hypertension
Pregestational Type 1 or 2 diabetes
Kidney disease
Autoimmune disease, such as lupus

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Low-Dose Aspirin �(75-100 mg)

Pregnant individuals with two or more of the following moderate risk factors:

Nulliparity
Obesity (Body mass index >30)
Family history of preeclampsia (e.g., mother or sister)
Black race (as a proxy for underlying racism)
Lower income
Age 35 years and older
Personal history factors (e.g., low birth weight or small for gestational age)
In vitro fertilization

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Antihypertensive Medications

The American College of Obstetricians and Gynecologists (ACOG) recommends utilizing 140/90 as the threshold for initiation or titration of medical therapy of chronic hypertension in pregnancy, rather than the previously recommended threshold of 160/110.

Source: Clinical Guidance of the Integration of the Findings of the Chronic Hypertension and Pregnancy (CHAP) Study

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Postpartum Follow-up Visits

Self-monitoring blood pressure until a visit with healthcare provider within 7-10 days after delivery OR
A visit with healthcare provider within 72 hours (3 days) for those with severe hypertension

Following this initial contact, it’s recommended that ongoing care be provided as needed including a comprehensive postpartum visit within 12 weeks of birth.

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Beyond Pregnancy: Your Emotional and Physical Health MATTERS

Schedule an annual visit with your primary care provider
Monitor your blood pressure
Be active 150 minutes a week
Eat a healthy diet
Lowering the amount of salt in your diet
Live smoke-free
Aim for a healthy body weight
Speak to your health care provider before planning your next pregnancy

Talking Points:

Healthy weight management and regular exercise before and during pregnancy further reduce preeclampsia risk. Studies have shown that incorporating 25-minute sessions of either aerobic or strength training at least three times a week was particularly effective in reducing hypertensive disorders in pregnancy.
The Diabetes Prevention Program funded by the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC), showed that by eating healthier, increasing physical activity, and losing a small amount of weight, a person with pre-diabetes can prevent or delay the onset of type 2 diabetes by 58%. Diabetes is a risk factor for preeclampsia.
The American Heart Association recommends no more than 2,300 milligrams of sodium a day. 1 teaspoon salt = 2,300 mg sodium. The ideal limit is no more than 1,500 per day for most adults, especially for those with high blood pressure. Cutting out just 1,000 milligrams a day can improve blood pressure and heart health.
What are some ways we, as Home Visitors/CHWs, can encourage our clients/families to make changes and practice a healthy lifestyle?

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QUESTIONS

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Self-Monitoring Blood Pressure (SMBP)

Educating clients on how to accurately take a blood pressure using a validated device/monitor and upper-arm cuff
Usually done at home or outside the healthcare clinic setting
Best way for women to know and understand their blood pressure patterns

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Alicia’s Story

https://millionhearts.hhs.gov/tools-protocols/tools/hypertension-disorders-pregnancy.html

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SMBP Education

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What is SMBP?

Refers to blood pressure measurements taken outside of the clinical setting, usually at home.

Helps with diagnosis and management of hypertension and increases client participation in their own care.

Combined with other clinical supports, improves hypertension control.

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Hypertension in Pregnancy - Gynecology and Obstetrics - MSD Manual Professional Edition

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PREPARE: What should you avoid before taking your blood pressure?

POSITION: What is the proper position for taking a blood pressure?

MEASURE: How many measurements do you need to take? When is the best time for taking your blood pressure readings?

RECORD: How are you going to record (log) your blood pressure readings?

REPORT: How are you going to share your blood pressure results with your healthcare provider/team?

SMBP Education

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Recording and Reporting Blood Pressure Readings

Paper/calendar log, pen/pencil (include date, time of day)
Tracking form/ BP log
Texting (send client text reminders to report BP numbers)
Wallet card
Mobile apps (e.g., Heart Habit, SmartBP, or OMRON Connect)
Patient portal
Device Memory
Photographs
Other ideas?

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Providing Support and Empathy

Use listening skills to guide the conversation and coach.

Use open-ended questions, reflections, summaries, affirmations, and ask for permission.

Create a safe and judgement-free environment.

Assist patient/client to identify barriers to monitoring their blood pressure at home. Provide support by using the SMBP Action Plan.

Celebrate efforts!

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Resources

Educating Patients (preeclampsia.org)

Hear Her Campaign: cdc.gov/hearher/pregnant-postpartum

American Heart Association: https://www.heart.org

Alliance for Innovation on Maternal Health (AIM): https://saferbirth.org

American Medical Association: https://map.ama-assn.org/resources

The American College of Obstetricians and Gynecologists: https://www.acog.org

Centers for Disease Control (CDC): https://www.cdc.gov/nchs/data/hestat/maternal-mortality-rates

Michigan Maternal Mortality Surveillance (MMMS) Program: https://www.michigan.gov/mdhhs/adult-child-serv/childrenfamilies/mmms

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Resources (continued)

Hypertension in Pregnancy Change Package: millionhearts.hhs.gov/tools-protocols/action-guides/hypertension-pregnancy-change-package

Healthy Hearts Resources: Michigan Department of Health and Human Services (MDHHS):
https://www.michigan.gov/mdhhs/keep-mi-healthy/chronicdiseases/cardiovascular/healthy-hearts

Kent District Library - Check out a blood pressure monitor/kit: Blood Pressure Monitoring | Kent District Library

US Blood Pressure Validated Device Listing: https://www.validatebp.org

National Maternal Health Hotline: 1-833-TLC-Mama

https://mchb.hrsa.gov/programs-impact/national-maternal-mental-health-hotline

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��THANK YOU!��If you have any questions, please email: mmiracle@msu.edu��https://maternalhealthlab.chm.msu.edu/tools

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Hands-on Practice: Using a digital upper arm blood pressure monitor