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Abstract

Objective: Women with prior hypertensive disorders of pregnancy (HDP) have increased risk of developing future cardiovascular disease. The objective of this scoping review was to map the literature regarding the use of eHealth measures in cardiovascular follow-up after HDP and identify research gaps. Methods: A systematic search was conducted in four databases. Primary research articles and guidelines were included. Abstract screening, full-text assessment and data extraction was performed to summarize the findings. Results: The search identified 4830 articles and 12 guidelines. Eleven publications and one guideline were included in the analyses. Various eHealth interventions were assessed, such as remote blood pressure monitoring, physical activity and weight management, with follow-up time from 6 weeks to 4 years. eHealth interventions targeting blood pressure and physical activity showed statistically significant positive effects. Conclusion: The scoping review identified eHealth interventions for cardiovascular follow-up after HDP that may empower women to optimize their cardiovascular health.

Keywords

preeclampsia gestational hypertension cardiovascular disease mHealth telemedicine postpartum

Introduction

Hypertensive disorders of pregnancy (HDP) affect 2-8% of pregnancies worldwide and remain a high morbidity and mortality burden for both mother and offspring.^1,2 In addition to the increased risk of maternal morbidity and mortality during pregnancy, delivery and the postpartum period, HDP also entails long-term maternal health challenges.^3,4 Population-based epidemiological studies have shown that a history of HDP is associated with increased risk of future cardiovascular disease (CVD) in women, with a 2- to 8-fold increased risk of cardiovascular death.³ Furthermore, this association is also present following other pregnancy complications, such as fetal growth restriction (FGR), spontaneous preterm delivery and gestational diabetes mellitus.^5–7 The potential mechanisms for these associations likely include both shared risk factors for HDP and CVD as well as pregnancy-mediated risk factors.⁸

After pregnancy, it is generally recommended that women with HDP should be offered a preventive cardiovascular follow-up, with appropriate management of any identified CVD risk, although there is no global consensus on the type or frequency of such follow-up.⁸ Population-based studies from Denmark and Norway indicate that one-third of women after HDP develop hypertension within 10 years postpartum.^9,10 This supports the concept that interventions to prevent CVD in the affected women are optimally initiated early in the postpartum period.¹¹ Blood pressure monitoring after HDP is one of the recommendations in a United Kingdom guideline from the National Institute for Health and Care Excellence (NICE).¹² It has been demonstrated that home-measured blood pressure may be superior in diagnosing true hypertension compared to office-monitored blood pressure in some high-risk groups.¹³ In addition, home monitoring of risk factors is likely to assist in empowering women in improving their own cardiovascular health, as is demonstrated with self-monitoring of blood pressure during pregnancy.¹⁴

The evolution of technological solutions has provided several electronic health (eHealth) tools that may play a crucial role in the future of healthcare. Telemonitoring and digital interventions have a potential to support self-management.^15,16 Telehealth interventions may improve postpartum care after HDP.¹⁷ However, to the best of our knowledge, there are no reviews on the topic of postpartum cardiovascular follow-up after HDP focusing on the utilization of eHealth tools.

This scoping review therefore aimed to map the existing scientific literature on the use of eHealth technologies for cardiovascular follow-up and cardiovascular disease prevention, particularly within the first years after an HDP pregnancy. We aimed to describe research on maternal modifiable risk factors for CVD and to identify research gaps to inform future clinical eHealth-supported follow-up studies.

Material and methods

Protocol and framework

The scoping review was conducted consistent with the Joanna Briggs Institute (JBI) methodology.¹⁸ A study protocol was created prior to commencing the systematic literature search.¹⁹

The methodological framework by Arksey and O`Malley, and Levac et al. and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist were used as a guide.^20–23

Research questions

Our primary research question was:

- Given the knowledge that HDP confers an increased long-term risk of maternal CVD, is there any current evidence for eHealth technologies contributing positively to the postpartum follow-up of cardiovascular risk factors and outcomes?

Our secondary questions were:

- Population and context: Which forms of HDP has this been studied for? What characterized the study populations?

- Aims and interventions: What were the aims of the studies? Which kinds of eHealth interventions have been tested? How long was the follow-up period?

- Outcomes: Which outcomes have been assessed?

- Findings: What were the key findings from the studies?

- Evidence gaps: Finally, we wanted to identify what gaps exist in the current literature.

Eligibility criteria, information sources and literature search

The population, concepts and context (PCC) framework was used to map out the research question and eligibility criteria. The population included in this scoping review are nulliparous and parous women with a recent HDP. The concept included the use of eHealth technologies in the first postpartum years in the clinical follow-up for long-term maternal cardiovascular risk after a HDP pregnancy. The context of the search was healthcare settings worldwide, where follow-up care after HDP pregnancies is given by skilled healthcare workers or home-based follow-up that is linked to an organized healthcare program. We included primary research articles that examined the use of eHealth technologies in the follow-up after a pregnancy complicated by HDP and its effect on outcomes related to cardiovascular risk. In addition, we also considered guidelines and protocols. Review articles were excluded. The protocols without published full text were excluded in the full-text review step. The most common forms of HDP are gestational hypertension and preeclampsia. Gestational hypertension is defined as new-onset hypertension (≥140 mmHg systolic and/or ≥90 mmHg diastolic blood pressure) developing from 20 weeks of pregnancy.²⁴ Preeclampsia (PE) is a multisystemic and more severe form of hypertensive complication during pregnancy, with potential life-threatening consequences for both mother and offspring. Preeclampsia is defined as gestational hypertension accompanied with at least one other sign of organ dysfunction associated with PE (such as proteinuria or elevated concentrations of creatinine or liver enzymes), arising de novo in the latter half of pregnancy.²⁴ Hemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome and eclampsia, that are more severe forms of preeclampsia, were also included in the review.²⁴ A pregnancy with chronic hypertension or superimposed preeclampsia (in women with chronic hypertension) was not an inclusion criterion, but neither an exclusion criterion if preeclampsia and/or gestational hypertension constituted the majority of the included participants in the published studies. Superimposed preeclampsia is defined as an additional preeclampsia-related sign of organ dysfunction in a woman with chronic hypertension, such as new-onset proteinuria after week 20 of pregnancy.²⁴

The databases selected for the search were Ovid MEDLINE, Ovid Embase, Maternity & Infant Care (MIDIRS) and Cochrane Database of Systematic Reviews. The search was conducted by an experienced librarian together with one of the authors (SB) on December 12, 2023 and an updated search was done on September 19, 2025 (Appendix 2). There were no time restrictions regarding the earliest publication year in the literature search. Additional searches were performed to retrieve unique references indexed in African Index Medicus and Global Index Medicus, but these did not yield any additional studies. The references were downloaded to EndNote reference management software (version 21; Clarivate Analytics, USA).

Selection of sources of evidence, data charting and synthesis of results

Covidence systematic review software (Veritas Health Innovation Ltd, Australia) was used for managing the retrieved literature. Initially, duplicates were removed. Thereafter the remaining titles and abstracts were reviewed by two of the authors (SB and BSF) independently. The authors worked independently throughout this process. They compared their findings after reviewing the first 10 randomly selected titles and abstracts to ensure that they had a similar understanding of the predefined inclusion and exclusion criteria. The sources labelled “yes” or “maybe” underwent full-text review. All reviewers are fluent in English, Norwegian, Danish and Swedish, and the literature published in other languages was excluded prior to the full-text review step. Subsequently, the full text was examined. The reference lists of the retrieved full-text literature were searched for relevant new articles. Any discrepancies in the abstract screening or the full-text examination steps were resolved by a third reviewer (MS). Data charting was conducted by using a data charting form by two of the authors (SB and BSF). This was validated by first charting three articles independently to ensure a mutual understanding. The final version of the data charting form was uploaded to Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia, available at https://www.covidence.org/) (Appendix 3). Country of origin, aim, population characteristics, HDP definition, methods, intervention, outcomes, results and other relevant information were extracted from the retrieved papers. A separate data charting form was designed and used to align with the structure of guidelines (Appendix 4). In case of discrepancies in the data charted, the reviewers reached consensus by discussion. Consistent with the JBI framework for scoping reviews,¹⁸ we did not perform any formal quality assessment of the included articles or synthesize effect estimates. The information from the data extraction for each of the finally included research articles is summarized in Table 1. The results from guidelines are presented in Appendix 4.

Table 1.

Data extraction of the included articles (alphabetical order).

Study published year Country	Study design	HDP definition Type of HDP studied	Population characteristics	Aims	Intervention	Follow up period	Outcomes measured	Key findings
Cairns et al. 2018 United Kingdom³²	RCT, multicenter (5 study centers)	NICE 2011	91 participants in total requiring antihypertensive medication:	Evaluate the feasibility and effects on self- management of BP of postpartum HT	Daily BP monitoring at approximately the same time using a validated device	6 months	Primary: - Recruitment, retention and compliance with follow-up rates	Primary: - Retention 6 months 89% in intervention group - OR 5.4 (95% CI 1.7-17.6) for reaching BP target in intervention compared to control group at 6 weeks. Not significant at 12 and 26 weeks
		- GH	45 intervention		Participants typed the BP reading into their phone and telemonitoring service gave feedback on the BP values
		- PE	46 usual care		Standard care group: BP monitoring at community midwife and adjustment of medication through GP		Secondary: - Mean SBP, DBP and mean arterial pressure - Postnatal readmission rate, safety data, side effects and quality of life (EQ-5D-5 L)
		- PE	46 usual care					Secondary: - Mean difference in diastolic BP -4.5 mm Hg (95% CI −8.1 to −0.8) remained significant until 6 months. - No difference in mean systolic BP - Eleven adverse outcomes reported (5 from the self-management group) −2 of 203 in the intervention group and 4 of 209 in the control group had readings outside the defined safety ranges - Side effects reported were similar between the groups. - No between group difference in QoL score
Hauspurg et al. 2023 USA³³	Three arm RCT	ACOG 2019	Home blood pressure monitoring (HBPM) alone, n = 49, HBPM + Heart health 4 new Moms (HH4NM), n = 51, control n = 48.	Examine the feasibility of conducting an RCT comparing home blood pressure monitoring plus the internet-based lifestyle intervention HH4NM	HBPM: Home BP monitor with automated text message reminders, and access to HH4NM control website with publicly available information on cardiovascular risk after HDP and lifestyle recommendations.	12 months	Primary: - Feasibility of recruitment and retention. Success included randomization of 8–10 participants per month and retention of ≥80% of participants to 1 year postpartum	Primary: −148 of 400 eligible were recruited 37% (95% CI 32.2–41.9) over a 23-month period. −129 of 148 competed the second study visit, 87.1% (95% CI 80.6–91.6) - Retention 76% in HH4NM + HBPM, 86% HBPM, 100% control
		- GH			HBPM + HH4NM: All interventions for HPBM, plus electronic scale and access to HH4NM lifestyle programme website which included modules on healthy lifestyle habits.
		- PE			Control: Access to HH4NM control website.		Secondary: - Weight, blood pressure change, adherence to intervention, self-efficacy, prevalence of HT, antihypertensive use at study completion, prevalence of lifestyle behaviors
		- PE			Control: Access to HH4NM control website.			Secondary: - No significant differences in weight and BMI follow-up visit and enrolment across the study arm −58% met the criteria for stage 1 HT and 22% for stage 2 HT and no significant difference between study arms - No difference in self-efficacy towards healthy eating and activity across the study
Hirshberg et al. 2023 USA³⁴	RCS	ACOG 2020	1700 participants in intervention group, who were matched to two groups:	Evaluate the association of text-message based remote BP monitoring program and adverse postpartum clinical outcomes and costs in patients with HDP	Remote monitoring program. Automated BP monitor and text message reminders. Patients send their BP values via text message and receive automated feedback	12 months (but data presented for 6 months)	Primary: - Composite adverse outcome - Adverse clinical outcomes post-discharge such as stroke, DIC, eclampsia, pulmonary edema, HELLP syndrome, myocardial infarction	Primary: −6 months after delivery the remote monitoring group were less likely to have composite adverse outcome than in cohort A [(2.9% vs 4.7%, OR 0.6 (95 % CI 0.40–0.98)]
		- GH	1021 in cohort A and 1276 in cohort C
		- PE	Cohort A: Participants at the three study centers before implementing remote monitoring program					Secondary: - The intervention group had more cardiologist visits and fewer emergency department visits. - Total medical costs for the program cohort were significantly reduced due to fewer emergency department visits and readmissions. The savings for the program were $32.20 per member per month compared to cohort A (95% CI $24.90–39.50) and $29.40 per member per month compared to cohort C (95% CI $25.90–32.90), after the first 6 months.
		- HELLP	Cohort C: Participants at other hospitals during the same period as clinical use of the program was used				Secondary: - Total medical cost and healthcare service utilization including specialist visits and all-cause inpatient readmissions 6 months after delivery
		- Eclampsia
		- Chronic HT with superimposed PE
Kitt et al. 2021 United Kingdom³⁵	RCT multicenter (5 study centers)	NICE 2011	61 participants:	Assess long term BP control in women with a history of HDP	Self-monitoring their BP once daily at approximately the same time using a validated BP monitor. The BP readings were entered into their phone and the tele monitoring service provided automated response.	Up to 4 years	Primary: −24-h average diastolic blood pressure assessed by 24-h ambulatory BP monitoring	Primary: −24-h diastolic BP was lower in the intervention group compared to usual care. Mean difference adjusted for BP at delivery: −7.4 mmHg (95% CI −10.7 to −4.2) - Adjusting for current salt intake, age, body mass index, waist-to-hip ratio, arm circumference, parity, alcohol intake, and physical activity had no effect on this difference
		- PE	30 intervention		If the readings were high according to the NICE guidelines participants were asked to contact NHS immediately
		- GH	31 usual care				Secondary: −24-h average systolic BP - Mean diurnal diastolic and systolic BP, nocturnal systolic and diastolic BP, clinic systolic and diastolic BP during study visit - Mean EuroQoL visual Analogue scale scores
		- GH	The participants were recruited from the original SNAP-HT trial					Secondary: - Diurnal diastolic BP was −5.3 mmHg (95% CI -8.6 to −2.0) lower in the intervention group. - Nocturnal diastolic BP was −7.8 mmHg (95% CI -11.9 to −3.7) lower in the intervention group - Nocturnal systolic BP was −7.4 mmHg (95% CI -14.2 to −0.7) in the intervention group. −24-h and diurnal systolic BP did not significantly differ between the groups. - Clinic diastolic and systolic BP did not significantly differ between the groups.
Kitt et al. 2023 United Kingdom³⁶	RCT, single center	NICE 2019	220 participants:	Evaluate to if physician-guided self-management is better designed to achieve better BP control in the postnatal period is associated with lower BP than usual outpatient care during the first 9 months postpartum	Bluetooth-enabled enabled BP monitor combined with a smartphone app	6 to 9 months	Primary: - Mean 24-h diastolic BP 6-9 months postpartum, adjusted for baseline postnatal BP	Primary: - Mean 24-h diastolic BP at mean 249 (SD 16) days postpartum was −5.8 mm Hg (95% CI −7.40 to −4.20) lower in the intervention group compared to the control group
		- PE	112 intervention		Usual care: which is typically a BP review of 7-10 days with a community midwife and a 6–8-weeks review with their general practitioner
		- GH	108 usual care				Secondary: - Mean 24-h systolic BP - Diurnal and nocturnal systolic and diastolic BP - Systolic and diastolic clinic BP - Assessment of cardiac structure (published in Kitt et al. 2024³⁷)	Secondary: - Mean 24-h systolic BP was −6.51 mm Hg (95 % CI −8.80 to −4.22) lower in the intervention group compared to the control group - Mean diastolic clinic BP was −4.17 mmHg (95% CI -6.28 to −2.06) lower in intervention group - Mean systolic clinic BP was −5.64 mmHg (95% CI -8.43 to −2.84) lower in the intervention group
Kitt et al. 2024 United Kingdom³⁷	RCT, single center	NICE 2019	220 participants in the trial	Assess adverse cardiac remodeling in women with history of hypertensive disorders of pregnancy	Same as Kitt et al. 2023³⁶	6 to 9 months	Primary: −24-h mean diastolic BP (reported in Kitt et al. 2023³⁶)	Secondary (primary see Kitt et al. 2023³⁶): - Relative wall thickness as assessed by echocardiography was 0.06 (95% CI 0.07–0.05) lower in intervention group compared to controls between baseline and follow-up. - CMR at follow-up showed lower left ventricle mass: −6.37 g/m2 (95% CI -7.99 to −4.74) and a higher left and right ventricular ejection fraction by 2.6% (95% CI 1.31–3.92) and 2.8% (95% CI 1.4–4.1), respectively. - Echocardiography showed improved diastolic function at follow-up: Average E/E` −0.52 (95% CI -0.97 to −0.07) and left atrial volumes −4.33 mL/m², (95% CI -5.52 to −3.21).
		- PE	Total 187:
		- GH	101 intervention, 86 controls underwent echocardiography				Secondary: - Cardiovascular imaging outcomes using transthoracic echocardiographic assessment at V1 (around delivery) and V4 (9 months postpartum) and CMR structure at V4
			Total 174:
			93 intervention
			81 controls underwent cardiac MRI
Kokai et al. 2025 The Netherlands³⁸	RCT	Definitions not provided	Total 663: 619 randomized 209 motivation group	To test the effectiveness of two 8-weeks app-based minutes per week of moderate to vigorous physical activity (MVPA) interventions (motivation and action) that were based on the integrated behavior change model	Wearable fitness tracker and a physical activity intervention app with weekly modules.	61 weeks	Primary: - Minutes per week MVPA	Primary: - Mean weekly MVPA for all 3 groups were reduced from a baseline of 242 min (SD 190) to 197 min (SD 208) minutes immediately post intervention - No significant treatment effects were observed for MVPA after 9 weeks of treatment in either the action group: −17 min/week (95% CI -58 to 23) or the motivation group: −3 min/week (95% CI -58 to 51)
		- Preeclampsia, HELLP			205 action group		Primary: - Minutes per week MVPA
		- «Other HDP»			205 controls		Secondary: - Mean wearable fitness tracker measured daily resting heart rate and self-reported measures BMI, waist-to-hip ratio, cardiorespiratory fitness level and subjective well-being.
					Motivation group: Get motivated module based on motivational interviewing techniques.
					Action group: Get motivated module plus get Activated and get energized modules, focusing on action planning and stress reduction respectively.			Secondary: - Improvements were observed for most of the secondary outcomes in all three groups, however this was not hypothesis tested due to lack of effect observed for the primary outcome.
Lewey et al. 2022 USA³⁹	RCT	ACOG guidelines 2020	127 participants in total:	Determine whether a digital health intervention improves physical activity among individuals with hypertensive disorders of pregnancy	All participants received a wearable activity tracker. This tracked their baseline. The participants set a step goal higher than baseline and randomized	12 weeks	Primary: - Mean daily step count from baseline to 12-weeks follow-up difference	Primary: - The intervention group had a significantly greater increase in mean daily steps compared to the control group 647 steps (95% CI 169-1124) after adjusting for baseline steps and calendar month.
		- GH	63 intervention		Intervention: Team-based gamification with a game with points and levels for daily step goal and based on principles from behavioral economics
		- PE (with or without severe features)	64 controls		Control group: Received daily automated text messages on goal attainment		Secondary: - Proportion of participant-days step goals was achieved - To determine whether women who daily self-weighed lost more total weight between delivery and 6 weeks postpartum	Secondary: - The intervention arm achieved their goals for daily number of steps on a greater proportion of participant-days during the intervention period compared to controls [0.47 vs 0.38, adjusted difference 0.11, (95% CI 0.04-0.19)] Median weight loss in the remote blood pressure monitoring program was the same as in controls: 23.0 pounds (IQR 17–30) vs. 23.0 pounds (IQR 17–29)
		- Eclampsia
		- Chronic HT (with or without PE)
Lohr et al. 2023 USA⁴⁰	Non-randomized trial	Not specified which guideline used	428 participants:	Examine the impact of daily self-weighing via remote monitoring on weight loss postpartum	Intervention: Tablet device, blood pressure equipment and a bluetooth-enabled scale was given to the participants Instructed to take daily blood pressure and weight measurement	6 weeks
		- GH	214 intervention
		- PE	214 usual care
		- HELLP			Control: Usual standard care 72 h postpartum blood pressure evaluation outpatient or inpatient. 7 to 10 days postpartum outpatient blood pressure evaluation
		- Eclampsia
		- Chronic HT
		- Superimposed PE
Muijsers et al. 2022 The Netherlands⁴¹	RCT, multi center (seven studycenters)	ISSHP 2014	198 participants:	Evaluate home BP monitoring in women with history of PE/HELLP syndrome is feasible for detecting and management of HT	Intervention: The participants received home BP monitoring and measured their BP for seven consecutive days each month for a year, preferably twice a day. The BP measurements were entered into an online patient health file. Monthly feedback was provided on their BP measurements and lifestyle advice was provided if relevant.	12 months	Primary: - Evaluate the feasibility of home BP monitoring	Primary: - Protocol adherence decreased during the first 6 months and stabilized after this - Protocol persistence remained high throughout the follow-up period
		- PE	99 intervention		Control: No planned BP measurement but asked to register their BP measured at home or at a general practitioner. 1-year follow-up for all participants with BP measurements and questionnaires		Primary: - Evaluate the feasibility of home BP monitoring
		- Eclampsia	99 usual care				Secondary: - Compare the BP levels, prevalence of cardiovascular risk factors such as HT, smoking and BMI between intervention and control group
		- HELLP syndrome	99 usual care					Secondary: −33 women in the intervention group (34%) and 10 women in the control group (11%) were diagnosed with HT during the study period, p < 0.001 - Mean diastolic BP were 77.1 mm Hg vs 91.7 mm Hg, p < 0.001 - Adjusted systolic and diastolic differences between intervention group and controls were −6.81 mmHg (95% CI -10.17 to −3.45) and −4.93 mmHg (95% CI -7.26 to −2.61), respectively.
Rich-Edwards et al. 2023 USA⁴²	RCT (recruited all over the USA)	ISSHP 2001	151 participants:	Reduce cardiovascular disease by testing online intervention to improve healthy lifestyle for women with recent PE	Heart health 4 Moms (HH4M) lifestyle program website: Audiovisual modules on topics such as, health eating, using the balanced plate and DASH diet, increasing physical activity and identifying promoters and barriers to adopting a healthy lifestyle	9 months	Primary: - Test to which extent the intervention in 9-months would improve self-efficacy to reduce cardiovascular risk by adopting to a healthy lifestyle and improve the knowledge of risk of cardiovascular disease after PE and a sense of personal control over that risk	Primary: −84% of the participants in the intervention arm completed at least one of the online modules −89% completed three or more scheduled calls with the coach - Intervention group reported greater knowledge of cardiovascular risk (p = 0.001) and self-efficacy for healthy eating (p = 0.03) and less physical inactivity compared to controls (p = 0.0006) - No differences in sense of personal control of cardiovascular disease risk factor, adherence to DASH diet, self- efficacy for physical activity or reported physical activity
		- PE	76 intervention		Control: Received internet links to cardiovascular risk reduction information
			75 controls				Secondary: - Test the extent to which the program would lower weight and BP
			75 controls					Secondary: - No differences in secondary outcomes

Abbreviations (alphabetical order): ACOG = American College of Obstetricians and Gynecologists, BP = Blood pressure, 95% CI = 95% confidence interval, CMR = Cardiac magnetic resonance, DASH diet = Dietary Approaches to Stop Hypertension diet, GH = Gestational hypertension, HDP: Hypertensive disorders of pregnancy, HELLP = Hemolysis, Elevated Liver enzymes and Low Platelets, HT = Hypertension, IQR: Interquartile range, ISSHP = International Society for the Study of Hypertension in Pregnancy, MVPA = moderate-to-vigorous physical activity, NICE = National Institute for Health and Care Excellence, PE = Preeclampsia, QoL = Quality of life, RCS = Retrospective cohort study, RCT = Randomized controlled trial, SD = Standard deviation.

Results

Selection of sources of evidence

The search across the selected databases identified 4831 references. Eight duplicates were removed. After searching the reference list of the full-text articles, seven studies were added, where one was a duplicate. 12 guidelines were also manually added to the search. In total, 4830 studies were screened for titles and abstracts, of which 4753 studies were excluded. The remaining 77 studies underwent full-text review, and 66 of these were excluded. In total, 11 primary articles were included after the full-text review.

Twelve obstetric and cardiologic guidelines were also searched as grey literature (Appendix 4), both from international expert bodies [World Health Organization,²⁵ The International Society for the Study of Hypertension in Pregnancy (ISSHP),²⁴ The International Federation of Gynecology and Obstetrics²⁶], as well as regional expert bodies [(Society of Obstetric Medicine of Australia and New Zealand,²⁷ The European Society of Cardiology (ESC),²⁸ American Heart Association (AHA),²⁹ American College of Obstetricians and Gynecologists (ACOG)]³⁰ and national expert bodies [NICE¹² and Norwegian Society of Gynecology and Obstetrics].³¹ All these guidelines include recommendations for maternal cardiovascular follow-up after HDP. Only one of the guidelines mentioned eHealth interventions in cardiovascular follow-up, specifying its utility in blood pressure management.²⁸

Thus, 11 primary articles and one guideline were finally included in this review. The results from the included primary articles are displayed in detail in Table 1 and the results from the guidelines are presented in Appendix 4. Figure 1 shows the selection process in a PRISMA flow diagram.

Figure 1.

PRISMA flow diagram.

Characteristics of the included studies

A summary of the characteristics of the 11 included publications is presented in Table 1.^32–42 Kitt et al. 2023³⁶ and Kitt et al. 2024³⁷ are two publications from the same main study, which means in total 10 studies are described. The 11 included publications were published from 2018 onwards and the majority were published in 2023-2025. Study sites included United Kingdom,^32,35–37 United States^{33,34,39,40,42} and The Netherlands.^38,41 Most studies (nine of 11) were randomized controlled trials (RCT)^{32,33,35–39,41,42} and the two remaining studies were one retrospective cohort study³⁴ and one non-randomized trial.⁴⁰ The number of participants varied in the studies from 61³⁵ to 1700.³⁴ In Hirshberg et al. the 1700 participants enrolled in the remote monitoring program were each matched in two separate analyses to comparison cohorts with 1021 and 1276 participants.³⁴ Furthermore, the time from birth to intervention varied in the range of 1 day^36,37 to 13 years⁴¹ Eight of the 11 included publications described ethnicity, with seven of the studies having mainly a White population^{33–37,40,42} and one a majority of African American/Black women.³⁹ Overall, the follow-up period varied from 6 weeks to 12 months,^{32–34,36–42} with the exception of Kitt et al. 2021,³⁵ reporting a 4-year follow-up period.

Different definitions of HDP were used in the studies. Studies conducted in the United Kingdom predominantly used the HDP definitions given in the NICE guidelines,^{12,32,35–37,43} whereas the remaining studies used ACOG 2020 definitions,^30,33,34,39 ISSHP 2014^41,44 or ISSHP 2001.^42,45 Two of the studies did not specify which guideline was used for defining the subclassification of HDP.^38,40 Table 1 refers to which HDP definition guidelines were used in the follow-up studies after these pregnancy complications.

There was also a heterogeneity in the included HDP diagnoses between the nine studies. All studies included women who had been diagnosed with preeclampsia, eight also studied gestational hypertension, four eclampsia and three HELLP syndrome and three of the studies included superimposed preeclampsia and chronic hypertension. The studies from Cairns et al.³² and Kitt et al.³⁵ included women after preeclampsia or gestational hypertension who specifically required antihypertensive medication after hospital discharge. Hauspurg et al. included individuals who were overweight and obese following a pregnancy complicated with HDP.³³

One notable challenge reported in the included studies was the retention rate and adherence to the intervention. This varied across the reports: Cairns et al.³² reported an 89% retention after 6 months, whereas Muijsers et al.⁴¹ noted a 25% retention after 6 months, which stabilized at the 12-months follow-up. Some of the included studies used prompt/reminders, and interventions with proactive reminders, that may be more useful.^33–38

Management of cardiovascular risk factors after hypertensive pregnancies using eHealth interventions

All of the included studies focused on different cardiovascular risk factors in their eHealth intervention, except for the study by Rich-Edwards et al. that focused more on lifestyle change by risk education and information about a healthy lifestyle.⁴¹ However, none of the studies assessed overall CVD risk after an HDP pregnancy.

Most of the studies assessed blood pressure (BP) management.^32–37,41 The primary outcome of two of the studies was 24-h average diastolic BP.^35–37 Both had also other measurements of BP as secondary outcomes, with Kitt et al. 2023 and 2024 also assessing cardiac structure by echocardiography and cardiac magnetic resonance.^36,37 Most of the studies focusing on BP found a significant difference in BP between the intervention and control groups, with more optimal BP in the intervention group.^{32,35–37,41} Kitt et al. 2024 found on echocardiography a significantly reduced intraventricular wall thickness and reduced left ventricle mass compared to controls, around 9 months after an HDP pregnancy.³⁷ Hirshberg et al. showed that the intervention group with self-monitored BP was less likely to have a composite adverse outcomes such as post-discharge stroke, disseminated intravascular coagulation (DIC), eclampsia, pulmonary edema, HELLP syndrome and myocardial infarction.³⁴ In addition, the study reported that the total postpartum medical costs in the intervention group were lower compared to the control group.³⁴ Hauspurg et al. tested the feasibility and effect of a home blood pressure monitoring program alone or combined with a remote lifestyle intervention (Heart Health 4 New Moms) and compared this to a control group.³³ The combined intervention did not have statistically significant effect on blood pressure or weight-related outcomes compared to home blood pressure monitoring alone or control.³³

The trial by Lohr et al. investigated daily self-weighing at home for 6 weeks, demonstrating no difference in median weight loss between the intervention group and controls.⁴⁰ Lewey et al. assessed if eHealth intervention use in 12 weeks can improve physical activity by assessing mean daily step count.³⁹ The study presented significant increased mean daily steps in the intervention group as compared to controls. Rich-Edwards et al. tested the efficacy of a web-based intervention for 9 months to improve the participants’ lifestyle. However, the study did not find any differences between the groups in the main assessed clinical objective risk factors of CVD, such as weight and BP.⁴² The study from Kokai et al. also tested the effectiveness of an app that focused on moderate to vigorous physical activity (MVPA) and used wearable fitness tracker with an app including a motivation module and an action module, but found no significant difference between the three groups in weekly MVPA.³⁸

The eHealth interventions focused mostly on daily self-monitoring of BP with an automatic monitor,^{32,34–37,41} with Lohr et al.⁴⁰ and Hauspurg et al.³³ also including weight measurements with a Bluetooth-enabled scale. After patient-measurement of BP, the results were typed into a smartphone app,^{32,33,35–37} sent by text message,^32,34 or uploaded automatically to the server.^40,41 Some of the trials utilized daily reminders via phone or apps to motivate participant adherence.^33–37 Two of the studies had feasibility as their primary outcome.^32,33,41 In one of the studies focusing on self-management of BP and feasibility, the retention was 89% after 6 months,³² and the odds ratio (OR) was 5.4 for reaching the normotensive BP target in the intervention group compared to controls. Another study presented that the protocol adherence decreased the first 6 months, and stabilized at 25% at the 12-months follow-up. Both these studies showed that the mean diastolic BP was significantly lower in the intervention arm than for controls.^32,41

Lewey et al. utilized wearable activity trackers to assess physical activity level by step count.³⁹ One important strategy to notice, is that the authors tested a text-based gamification intervention, where the participants enrolled in virtual teams, obtaining game points if they reached their step-goal. The primary outcome in this study was effect on mean step count and secondary, the feasibility of the intervention. The authors found that the intervention group with gamification of physical activity registrations for 12 weeks had a greater increase in step count compared to controls, and also achieved the step goals on a greater proportion of days.³⁹

Rich-Edwards et al. used a lifestyle audiovisual website with topics such as diet, physical activity and barriers to a healthy lifestyle.⁴² The follow-up period was in a range of three to 12 months. The web-based lifestyle intervention program found that 84% of the participants completed one of the modules, 89% completed scheduled calls with a lifestyle coach and the intervention arm reported a higher knowledge about CVD risk and healthy diet, but no significant differences were found in weight and BP measurements.⁴²

Discussion

Summary of evidence

In this scoping review, we present an overview of the 11 included publications focusing on eHealth interventions in cardiovascular follow-up of women with prior HDP. These 11 publications were based on 10 different studies, describing various interventions targeted to different aspects of modifiable risk factors of CVD, such as BP, weight and physical activity.

Based on the results from our scoping review, eHealth interventions are not commonly used, but hold promise in postpartum follow-up programs after hypertensive disorders of pregnancy. Noticeably, BP management with self-monitoring of BP with a text-based or smartphone app response seems promising, as six of the nine included publications showed some significant improvements compared to the control groups.^{32,35–37,41} Home monitoring of BP may be particularly useful in detection of early hypertension,⁴¹ which implies opportunities for timely interventions to reduce risk of end-organ failure or dysfunction. The included studies did however have a short follow-up time, and did neither test nor provide a clear conclusion on the optimal length or start of monitoring after a hypertensive pregnancy.

Cardiovascular risk – postpartum time representing a window of opportunity?

Cardiovascular short- and long-term follow-up is important after HDP, as highlighted in both obstetric and cardiovascular guidelines.^24,28 Even though the associations between HDP and premature maternal cardiovascular disease have been recognized for more than two decades,^4,8,9,46 it is likely that few of the affected women are aware of the recommendations for follow-up.^47–49 Only one of the studies included in this review assessed knowledge about the association of HDP and cardiovascular risk. Participants using a web-based platform to provide information on these associations demonstrated significantly increased knowledge about their increased CVD risk after using the intervention.⁴² Therefore, eHealth interventions may represent important tools for providing empowerment and medical education to the group of women at risk.

Women who have given birth are usually relatively young, and lifestyle intervention in this period of time can be an ideal window of opportunity for prevention of later CVD.⁵⁰ Individualized optimization of modifiable risk factors can be an important strategy to reduce CVD risk.⁵¹ Guidelines from NICE,¹² ACOG³⁰ and the Norwegian Society for Gynecology and Obstetrics³¹ recommend that the woman’s primary care physician manages risk factors for cardiovascular disease after a pregnancy complicated by HDP. After hypertensive pregnancies it is recommended to maintain a healthy lifestyle. Some guidelines highlight the importance of self-monitoring in BP management.^13,28 In addition, it is recommended to estimate CVD risk postpartum, but an obstacle today is that there are no applicable cardiovascular risk calculators for young women.⁸ The currently available CVD risk calculators do also not include adverse pregnancy outcomes.⁵²

eHealth –integration into clinical care

eHealth opportunities are emerging in healthcare. eHealth-supported health interventions might represent an important strategy for early detection of modifiable risk factors for CVD after HDP, possibly improving self-efficacy and empowerment. Such measures need to assess the utility of the interventions compared to standard care, including cost-benefit analyses. The WHO guidelines⁵³ emphasize that assessment of the feasibility, acceptability and implementation is important when introducing and testing eHealth interventions. This review suggests that self-monitoring of BP and wearables with step-tracking can have benefits compared with standard care, but these interventions still warrant further research.

By searching among widely used guidelines in obstetrics and cardiology for postpartum care after HDP, we found only one expert guideline from ESC that contained information related to eHealth interventions.²⁸ The guideline²⁸ mentioned self-monitoring of BP as being of potential utility in the early postpartum period, referring to a study presented in this review.³⁶ However, this is an emerging field and further research on new eHealth solutions with longer clinical follow-up and patient-reported outcomes is essential to successfully transition eHealth interventions into clinical care.¹⁷

White females were overrepresented in all the included studies, except for one study.³⁹ In the United States, Black women have an increased risk of experiencing an adverse obstetric outcome such as HDP,⁵⁴ highlighting the need for interventions to reduce racial disparity and inequity. Furthermore, studies from United States have reported that home blood pressure monitoring can reduce racial disparity.^55,56

As the clinical burden of HDP is highest in low- and middle-income countries,^1,2 such as those of Sub-Saharan Africa, it is of concern that none of the included 11 publications are from such populations.^32–42 Thus, our review has limited external validity for low and middle-income countries. Future studies should aim to examine eHealth opportunities in populations that likely stand to benefit the most from better postpartum care after hypertensive pregnancy disorders.

Limitations

This scoping review is novel in assessing the use of and reported utility of eHealth technologies in the preventive follow-up of CVD risk after hypertensive disorders of pregnancy. However, it has some limitations, including that our review protocol is not peer reviewed. Our search could also have included more databases to identify grey literature. In addition, only English and Scandinavian language literature was included in the full-text examination, representing a potential source of bias. After acknowledging the presented limitations, we believe this scoping review answers our objectives and presents several remaining research gaps. We also propose further eHealth opportunities after hypertensive disorders of pregnancy complications.

Conclusion

In conclusion, this scoping review provides an overview of the existing evidence on the use of eHealth technologies in CVD risk follow-up and prevention after HDP pregnancies. eHealth interventions focusing on modifiable cardiovascular risk factors after HDP, such as BP management and physical activity, show statistically significant effect on managing CVD risk factors when compared to control populations.

We have identified a lack of eHealth-assisted research studies with a focus on long-term cardiovascular follow-up, as well as studies including women from low- and middle-income countries. We suggest that a personalized follow-up program benefitting from eHealth technology opportunities may have the potential to empower women to optimize their own cardiovascular health after hypertensive pregnancy complications, without increasing the demand for more healthcare resources.

Supplemental material

Supplemental Material - Hypertensive disorders of pregnancy: The use of eHealth technologies in postpartum follow-up strategies to reduce cardiovascular risk – A scoping review

Supplemental Material for Hypertensive disorders of pregnancy: The use of eHealth technologies in postpartum follow-up strategies to reduce cardiovascular risk – A scoping review by Shahana Balakumaran, Bendik S. Fiskå, Meryam Sugulle, Anne Cathrine Staff in Health Informatics Journal

Footnotes

Acknowledgments

The authors would express gratitude to Marie Susanna Isachsen, Senior Librarian at the Medical Library, University of Oslo, for her assistance with the literature search.

ORCID iDs

Shahana Balakumaran

Bendik S. Fiskå

Meryam Sugulle

Anne Cathrine Staff

Ethical considerations

This article does not contain any studies with human or animal participants.

Consent to participate

There are no human participants in this article and informed consent is not required as this a review.

Author contributions

Shahana Balakumaran: Conceptualization, Methodology, Investigation, Writing- Original draft preparation. Bendik S. Fiskå: Conceptualization, Methodology, Investigation, Supervision, Writing – Review & Editing. Meryam Sugulle: Supervision, Writing – Review & Editing. Anne Cathrine Staff: Conceptualization, Methodology, Visualization, Supervision, Project administration, Writing – Review & Editing.

Funding

No particular funding is applicable for the present study. PhD student BSF receives salary for research time work from Oslo University Hospital, whereas University of Oslo provides research time salary for Professors MS and ACS. Medical student SB receives no funding, as this project is part of a master project at University of Oslo, Faculty of Medicine.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Supplemental material

Supplemental material for this article is available online

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