The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care

Eunjung Choi, Brigitte Kazzi, Bhavya Varma, Alexandra R Ortengren, Anum S Minhas, Arthur Jason Vaught, Wendy L Bennett, Jennifer Lewey, Erin D Michos, Eunjung Choi, Brigitte Kazzi, Bhavya Varma, Alexandra R Ortengren, Anum S Minhas, Arthur Jason Vaught, Wendy L Bennett, Jennifer Lewey, Erin D Michos

Abstract

Purpose of review: The "fourth trimester" concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women's cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester.

Recent findings: A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness.

Summary: Development of a comprehensive postpartum care plan with careful consideration of each patient's risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.

Keywords: Adverse pregnancy outcomes; Blood pressure control; Cardiovascular disease; Fourth trimester; Prevention; Weight management.

Conflict of interest statement

Conflict of InterestDr. Michos reports Advisory Board participation for AstraZeneca, Bayer, Boehringer Ingelheim, Esperion, Novartis, Novo Nordisk, and Pfizer. No other authors report any disclosures.

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022, Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Figures

Fig. 1
Fig. 1
Snapshot of notable postpartum risk factors, multidisciplinary team members, and supplemental non-clinic interventions to be considered in postpartum cardiovascular care
Fig. 2
Fig. 2
Signs and symptoms of serious postpartum complications

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