Hypertension is killing pregnant mothers. Blood pressure monitoring can help. [PODCAST]

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“Hypertensive disorders with onset during pregnancies are among the leading causes of maternal and infant mortality and morbidity in the U.S. and can have far-reaching consequences for the long-term health of the mother and child.

In Dr. Jerome Adams’ recent Call to Action to recognize and address hypertension control as a public health priority, the former Surgeon General referenced the success of health care providers who have promoted shared management of hypertension through self-measured blood pressure monitoring (SMBP), empowering patients through blood pressure (BP) management and goal setting.

It’s not an unusual recommendation— SMBP is well accepted in primary care for managing hypertension — but its use in pregnancy has not been routine. That’s beginning to change for several reasons.”

Lauren Demosthenes is an obstetrician-gynecologist.

She shares her story and discusses her KevinMD article, “Hypertension is killing pregnant mothers. Blood pressure monitoring can help.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Lauren Demosthenes. She is an obstetrician-gynecologist, and she wrote the KevinMD article “Hypertension is killing pregnant mothers. Blood pressure monitoring can help.” Lauren, welcome to the show.

Lauren Demosthenes: Thank you so much. I’m excited to be involved with this and participate.

Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Lauren Demosthenes: So I’m currently the senior medical director of Babyscripts, which is a health care company that’s looking to innovate, accelerate, and improve maternity care, and the area of interest that I really have right now is the hypertensive portion of it.

Kevin Pho: You transitioned from a clinical role, or you still do a clinical role as an obstetrician-gynecologist, into being medical director of a medical device technology company. Tell me a little bit about that transition. Why did you make that transition in the first place?

Lauren Demosthenes: I finished my residency training a very long time ago, and I’ve always been the kind of person who questions why we do what we do. I was the first female physician in my community. I didn’t tread lightly. I questioned a lot: “But why? Why do we do this?” As my career kept going on, I provided maternity care to many, many women, and a lot of it just didn’t make sense to me. Why did we have people come in and sit in the office for a five-minute visit, a 10-minute visit? I myself have had three babies, and it just didn’t seem like the most efficient use of time for a woman.

So I really started getting interested in new models of maternity care, and it made a lot of sense to me, as a working mom, to not have to take time out of my day to go in to see a provider. I’m also really passionate about enabling women to be part of their health care. I thought, “Women can learn on their own if we provide them excellent resources.” Women can learn between visits, so that we don’t have to have a bearing field for four weeks and then teach them again. Women can learn how to take a blood pressure, like with the tool of Babyscripts. Women can do a lot on their own, and I want to empower them to take care of themselves during the maternity care process.

So I teach that a lot. I also teach at a medical school, and I teach the students to question why, not just memorize, but why. This opportunity to work with Babyscripts, and some other things that I do on the side, came up, and it really struck me that this is a good way to make a difference in health care beyond the patient in front of me. So I’ve jumped into that, with teaching about high-value care and innovation, and then working with a company that’s very forward-thinking, like Babyscripts. I also work with some national organizations, and that keeps me really fresh, because those are usually forward thinkers as well who really want to push the envelope and improve maternity care.

Kevin Pho: Now, for those physicians who are interested in doing that, looking for opportunities outside of the exam room or outside of the patient that’s in front of them, what kind of advice can you give these clinicians?

Lauren Demosthenes: I never considered myself highly academic, but I’m also the kind of person who really leans in and does a lot of cold calling or emails people. So I find somebody who has a similar interest, I’ll email them and just say, “Hey, looks like you have a similar interest. Would you collaborate with me, or can we have a phone call about this?” It is absolutely amazing how many high-powered people will say yes and embrace that. I’ve done that with the American College of OB/GYN, and I’ve done it with some really major health care leaders who probably answer my texts and emails more quickly than people in my own community. I’ve just had a lot of doors open through that process of asking to be involved, asking to help, and being part of national committees. So I’ve really enjoyed that.

Kevin Pho: I think I’m hearing that as a physician, your voice carries weight, because you mentioned that you did a lot of cold calling and cold email, and because of your background as a physician, people listened, or wanted to listen, to what you had to say.

Lauren Demosthenes: Yes, they seem to. The same thing happened with being a participant with Babyscripts. It’s just like, “I think that this is an awesome idea.” Then I would just send them articles that I read. I wasn’t the senior medical director; I just had a real interest in a lot of the things, and I’d say, “Wow, look at this. Maybe you could do this.” They’re extremely open-minded, and we had a lot of good discussions about what could be done better using technology and digital health.

Kevin Pho: So let’s transition into the KevinMD article that you wrote. It was back in March, and it’s titled “Hypertension is killing pregnant mothers. Blood pressure monitoring can help.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Lauren Demosthenes: So I was in charge of the hypertension safety bundle where I worked, and what I found out: Maternal hypertension is on the rise. The mortality from it is going down a little bit, but the number of women who actually have hypertension, and the number of women who will go on to have cardiac complications from that, is really on the rise. So we really need to intervene and educate.

The way we were doing it, the recommendations are to bring a woman back at 72 hours and again between 7 and 10 days to look at her blood pressure if she had a problem with her hypertension, and up to 10 to 18 percent of women have that. So we asked the woman, “Can you come back in 72 hours and then again next week?” Well, that is very difficult for a woman to do. Our no-show rate for that was extremely high, and that’s not just here; that’s nationally. A woman has a new baby, she doesn’t have transportation, she’s fatigued. How is she going to get back? I thought, “Why does she need to come back when we can do this remotely?” It was so simple in my mind that we were missing an opportunity.

So I got involved with a Robert Wood Johnson high-value care fellowship, and my research project was to look at that. The high-value care fellowship was looking at introducing more efficient ways, more patient-centered ways, to provide maternity care, and I was really focused on this postpartum hypertension, because we’re missing a lot of those women in the postpartum period. So that’s how it started. The company Babyscripts has a system that can allow this to be done much more easily for the patient, and really much more successfully for the physician, because the patients don’t have to come back. So that’s how that article, that research, and that passion started.

Kevin Pho: Now, can you give me a little bit of a case study or an illustration of a typical patient that you’re talking about? How high are these blood pressures that you’re talking about, and perhaps talk about what specifically are the potential complications from this being untreated?

Lauren Demosthenes: So take a woman who has a diagnosis of, let’s say, gestational hypertension. That’s not the really severe form of a hypertensive disorder of pregnancy, but we know those women are at very high risk of having an accelerated problem in the postpartum, and that’s why ACOG recommends that those women come back to see us, so that we can ask questions about things like headache and epigastric pain, and also so that we can potentially start them on a medication to lower their blood pressure. We know that the most common time that a woman would suffer a stroke, or something that is a consequence of hypertensive disorder of pregnancy, postpartum, is in that early postpartum period. So monitoring those people is really, really important.

A case study would be a woman who doesn’t come back for her visit, who then develops a headache, starts feeling poorly, comes to the emergency department, and we have a crisis on our hands. We have to admit her with a 170 over 110, put her on blood pressure medication, and treat her for potential eclampsia. What I really believed is that if we were in contact with a patient remotely, and we could look at trends and remind patients of the symptoms, we could possibly intervene before that, and maybe start her on medication at home before she gets to the crisis point. That has been proven out with Babyscripts, that early intervention can help, and with some other health systems as well that are doing these sorts of things. So again, it just makes total sense to me to identify problems before they’re problems, and also to remind women of this issue in the first 10 days, when she’s so wrapped up with taking care of her baby, feeding, and sleeplessness.

Kevin Pho: Now, with maternal hypertension in general, what’s the duration of how long they are potentially hypertensive for? Is it a period of weeks to months, and can it be indefinite?

Lauren Demosthenes: That’s what we’re learning. Now, typically in maternity care, we end the care at six weeks postpartum. The American College of OB/GYN has really emphasized that postpartum does not end at six weeks, that we should really be walking alongside these women for a year, and we’re trying to do advocacy to have payers reimburse for that. We’re learning more and more with the increase in hypertensive disorders of pregnancy: Although the deaths might be going down, this long-term hypertension is increasing. What does that lead to? It leads to heart failure, it leads to chronic hypertension, and kidney disease.

So we really want to transition the woman from maternity care to long-term care, and again, bridging that with technology, education, apps, and digital tools. Teaching a woman how to take her own blood pressure during pregnancy, and then making that part of her norm after pregnancy, makes so much sense. That’s what we’re trying to do through a forward-thinking tech company that is trying to make this transition into long-term care much easier for women, rather than just dropping off the radar.

Kevin Pho: Take me through the workflow of this technology in general when it comes to remote monitoring of blood pressure. So you diagnose the patient with maternal hypertension, and you prescribe or suggest this technology for your patient. Take me through the next steps. Take me through the workflow.

Lauren Demosthenes: It is prescribed. The best way to do it is to actually have the patient download the app and teach them how to use the blood pressure cuff as part of your workflow, which, with time in practice, can probably be done in five or 10 minutes. Patients are pretty tech-savvy, and they’re smart. They know how to use a blood pressure cuff. Then when they go home, they can enter their blood pressure readings as often as we think it’s necessary. In the postpartum, we like it to be done twice a day to establish a routine. Those blood pressures come into a dashboard that the physician can see, and the physician can see trends.

The big thing is that the company Babyscripts also, on the back end, knows what the blood pressure triggers are that they need to alert the physician about, and ACOG has guidelines of what those are, and those are established. But I could get a call from Babyscripts that says, “Hey, your patient has a 170 over 100. She’s on her way to the hospital.” So that’s good, and that may be without symptoms. So a lot of it is just using technology to extend what we can typically do.

Before we had this technology, in my years of practice, we would just tell the patient, “Hey, take your blood pressure. Call me if there’s a problem.” No follow-up, no instruction, no providing a cuff, just, “Hey, call me if you need me.” That’s the best we could do. We can just do so much better now. We can allow our patients to be part of their care, we can communicate with them daily, and we can monitor them daily, really from the comfort of a computer. And they know we’re watching them. They know we’re looking out for them on a daily basis. So again, it just makes sense to me.

Kevin Pho: We’re talking to Lauren Demosthenes. She is an obstetrician-gynecologist, and she wrote the KevinMD article “Hypertension is killing pregnant mothers. Blood pressure monitoring can help.” In terms of your journey to become a medical director of a technology company, did you have any other training outside of clinical medicine to help prepare you for that role?

Lauren Demosthenes: No, I did not, but I was very interested in digital health. I really serve as helping them guide the medical side of it, and helping them know about how a process may interrupt a normal workflow and some of the barriers that physicians have when they adopt new technology. So it’s the ear to the ground, having been there, seeing the resistance from care providers to doing something new, the skepticism, and helping them with that side.

And then I also just send them updates on all the other opportunities there are to extend care in that one year postpartum. Like I said, many women don’t come back for the postpartum visit, and what are some other things that can happen in that year? Well, we know they need support for mental health. That’s a huge area of concern right now, with suicide being one of the leading causes of death in the first year postpartum. If we can be there sending them supportive messages, sending depression screenings out to women in the postpartum, and helping care providers identify high-risk women, maybe we can help bridge that gap as well. So I think there are just a lot of opportunities to fill in that gap for women who either don’t have time or have difficulty getting in for that in-person visit.

In terms of the age group, this is the perfect age group to bring this in, because women in the childbearing age group are very used to technology. They’re used to apps, and they’re used to texting, so they’re very comfortable with it. And you don’t lose the connection with your physician, because they’re interacting on this platform. They know you’re watching their blood pressure. So Babyscripts makes really sure that that component is not gone. And of course, they can come in if they prefer, but a lot of women want both.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Lauren Demosthenes: That health care moves very slowly, and innovation and doing things in new ways is not always accepted with open arms. So you have to be prepared to know that it’s a slow process to make changes. A really good way to get involved with changes that occur more rapidly, or that are more forward-thinking, is to work with health care startup companies, get involved with your national organizations about policy change, and work with other forward thinkers. That can really help with burnout from your day-to-day job and get you over that hump of the slow change in health care.

Kevin Pho: Lauren, thank you so much for sharing your time and insight, and thanks again for being on the show.

Lauren Demosthenes: All right. Thank you so much.

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