← Dr. Chapa’s OBGYN Clinical Pearls 
Dr. Chapa’s OBGYN Clinical Pearls
Is OB HPBM “Evidence-Based”? BUMP1&2 vs SMFM Special Statement
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I've said it many times before, but it's worth saying again because it's true. Our podcast community is amazing. It is national and international and the comments and the insights and the queries that come into the show are solid. I mean, they're deep. Like this one that became basis for today's episode. Because I read this through one of our social media channels and I'm like, wow, that actually is a very complicated, brilliant and deep question. And there is an answer. There is a solid answer. And this has to do with how sometimes professional society guidance and community standard of care. Okay, remember that community standard of care is one thing. It isn't always the same as evidence based care. Now let me explain because before I irritate somebody, it would it generally follow that evidence based data would influence and make standard of care practice. And that is true in the majority of cases. However, there are times where the data is so conflicted and unclear that we cannot say that a practice is specifically evidence based. Nonetheless, it still remains community standard of care because those are two different things. Now how can that be that case? How can something be a community standard of care but not really have solid traditional data to back it up? Well, the answer is twofold. First is that there is data to back it up. It's just conflicted because if there's no data, then it wouldn't be a concern at all. It's just not done. But there is. Data is just conflicted, meaning not uniformly in agreement. Some say it doesn't do anything, some say it does. That's the first answer is that the Data is conflicted versus not there. So that's the first reason. And then the second reason, how something can be community standard of care and yet not be truly solidly evidence based is two key words and that is safety net. We're going to discuss this because this is very clearly stated in commentaries and this isn't my answer. I mean, this is actually an SMFM response that came out in 2023 regarding ambulatory and telemedicine in prenatal visits. Okay, this was in SMFM's special statement of 2023 and we're going to relate it to the specific question asked. Here we go guys, by a podcast family member. So in short, here's a question. Hey Dorothy, I'm a resident. I'm not going to say where and I'm not going to say who it is, but this is an OB PGY3 about to become a fourth year who asked his attending and said, hey look, I read Bump one and Bump two, both of which we have covered on this show in the past. Both of these had to do with randomized trials. They were both published in jama, they were both in the UK and they both focused on ambulatory, meaning home blood pressure monitoring. Those were in two separate populations. Bump one were those at risk for developing hypertension. Bump two were those with already a diagnosis of hypertension in pregnancy and said, knock yourself out, go, go home, check your blood pressures, use telemedicine and see if we can improve clinical outcomes. We're gonna compare these a little bit more detail after the intro. The short of it is, and the disappointment was that it really didn't seem to change clinical outcome. Preeclampsia wasn't found any better. There was no less progression of severe disease. Or like, meh, that's kind of disappointing. Bump one and Bump two big randomized non blinded clinical trials published in the UK that were kind of a wet blanket on ambulatory home blood pressure monitoring. Nonetheless, okay, nonetheless, we still incorporate home blood pressure monitoring and recommend that to our patients. So our PGY3, soon to be PGY4, had this question. If bump one and bump two didn't really show any benefit, why are we still recommending that? And why is that still an ACOGS practice bulletin number two two? We're going to answer all of There is a solid answer, guys, and look how deep that is. So this PGY3, soon to be PGY4 in a couple of weeks. Said the data here on randomized trials, big studies, very well respected. Bump one and Bump two Didn't really seem to show any benefit. Why are we doing this when there's a lot of room for error at home? So I gave him three answers. Number one, we've covered bump one and bump two in the archive. Go back and listen to that. But we're going to rehash that here very, very quickly. Number two, there is a possible disconnect at times between standard evidence based predominance of evidence and standard practice. And then the third answer is it has to do with the two words I already told you, safety net. I'm going to discuss what that means in this episode and we're going to focus on SMFM's special statement that was published in 2023 that actually answers this maternal fetal medicine special statement on telemedicine and obstetrics. The quality and safety considerations. This was out of ajog. So is OB home blood pressure monitoring evidence based? And if it's not, which I'm going to tell you now, it's not necessarily evidence based, it's conflicted. So why is it then community standard of care, it's deep and we're going to get to it very quickly here in this episode.
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We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast. All right, I promised Michael, our producer, we're going to do this quickly, but there's a lot to cover. But nonetheless, I have to be true to what I said I was going to do. So we're going to do this relatively quickly. First off, right off the bat, yes, ACOG does recommend ambulatory, otherwise known as home blood pressure monitoring in Practice bulletin number 222. Let me read that very quickly again, nothing new. We've covered this many times before and this is under the section inpatient or outpatient management for patients who do not have severe criteria. Right. You got to be stable and you can do ambulatory management at home. Totally reasonable for gestational hypertension or preeclampsia without severe features. No question you can do that. And under that section In Practice Bulletin 222, there's a small little sentence at the end where it says maternal evaluation. Here's what this would look like. Blood pressure measurements and symptom assessment are recommended serially. Here it is. Using a combination of in clinic and ambulatory approaches, with at least one visit per week in clinic, end quote. All right, there it is. So, yes, ACOG and SMFM absolutely still recommend home blood pressure monitoring, which is in the data. It's called hbpm. So if you can search that, you can do home blood pressure monitoring, ambulatory blood pressure monitoring, or HBPM in pregnancy. And it's right there. Now, the question is, why do we do that? Where is the data that. That's going to prevent disease progression? Catch this thing earlier and we're going to win this thing. So let me set this up. Number one, yes, there is data, but as I mentioned in the intro, it's conflicted, meaning it's definitely not a preponderance of evidence. We got some issues here. The jury would be a hung jury here if this was on trial because it's not a lot of strong data. There is data, but it's not all in the moving in the same directions. That's the problem we get into in a minute. But the second issue is it's not just giving a patient a blood pressure cuff and saying, knock yourself out, honey, go home, check your pressures whenever you want to. They need instruction. And I've mentioned this in the past, so the way that we do it is you gotta look at the arm, you gotta make sure that the cuff size is appropriate for the patient. You have to tell them, here's how to do it. Don't take it when you're lying on your, you know, on your back drinking your Dr. Pepper, because Texas loves Dr. Pepper. In other words, a largely caffeinated drink or drinking your espresso. Don't take your blood pressure doing that, and definitely don't do that if you're smoking, because you shouldn't be smoking. Anyway, the point is you need instruction. 30 minutes without physical activity. 30 minutes, hopefully at rest or at least 15. Legs not crossed. The arm cuff should be more or less at the level of the chest, and the patient should be in a relaxed state, not after a shouting match with their significant other. Right. So all of these things go into play here for ambulatory blood pressure monitoring. So there's a specific scheme here. And by the way, most of These studies haven't just been with home blood pressure monitoring. It's with some kind of connection. If you have a high blood pressure that's worrisome. You've got to be able to contact them quickly. So some of these are. The majority of these have been connected, at least in the clinical trials, through some sort of telemedicine option. All right, so, yes, it is an ACOGS practice bulletin. It is recommended. I'm not saying that it's not. It is guidance. The question is not if it's guidance. It is. It is. Does the data support that? And I found this so fascinating. So I was so excited, I messaged back to this resident. I'm like, man, brother, you need to be an attending or go into MFM or something, because that is deep. And so my first question was, well, what did your attending say? You asked your attending. What did the attending say? May I just say that I love you all. I really do. You know, God bless y'. All. I know everyone's trying their best. I mean, chef's kiss to everybody who works hard and loves their craft. And I'm just, again, I don't know. I wasn't there. This is the response that the resident told me that the attending said, we do it because we do it. Wow, that is deep, y'. All. That is some deep academic success right there, y'. All. Oh, my gosh. If you're. If you're the attending, and you actually said that, and I'm referencing this, I'm not mad at you at all. I'm not making fun of it at all. But really, couldn't we dig a little deeper down into the root solution here for an answer, rather than we do it? Because that's what we do. Wow. Yes, that is technically correct, but there is a deep answer to that. That is solid. Solid. And I'm going to tell you, because I don't even have to make one up. It's in 2023's ASMFM's special statement. Now, before I get into that, and again, not mad at you all if the attending, who is in reference here, who I don't know, said that. Again, chef's kiss to you. I appreciate you. Much Love to you, brother or sister. So let's very quickly get into bump one and bump two. Very quickly. I'm just going to summarize these. Supra. High level. And then I'm going to tell you why this thing was a big disappointment in what we thought it would do and nonetheless, why we still recommend home blood. Pressure monitoring very easy. So let's do bump one and bump two. The references for these of course will be in our show notes. But bump one, 2022, bump two also in 2022. Both are easy to remember because they're both in JAMA. JAMA, Journal of American Medical Association. The bump one trial was the effect of self monitoring of blood pressure on the diagnosis of hypertension during higher risk pregnancy. The bump one randomized clinical trial, end quote. So bump one were in those at risk of getting hypertension. So maybe they had a previous history. They're obese. They're obese and smoke. They're obese and smoke and say are Hispanic or African American. You get what I'm saying? So they have risk factors here, okay? Or they've got an autoimmune condition, whatever. So those at risk, bump 2 is the effect of self monitoring of blood pressure on blood pressure control in pregnant individuals with chronic or gestational hypertension. The bump 2 randomized clinical trial, end quote. So bump 1 was an early detection for those at risk. Bump 2 is you's already got a diagnosis of either chronic or gestational hypertension. And let's see if we can pick up preeclampsia or disease progression by you checking at home. Alright, so bump one is those at risk, bump two, they already got chronic or gestational hypertension. And let's see if we can detect you going down the drain quicker by you checking blood pressure at home. Okay, so those are the two different populations, both of them again randomized trials. Short of it is the big finding is womp, womp, womp. All right, so the big finding for bump one was that it did not lead to to earlier clinical detection of high blood pressure compared to standard care. And for bump two, womp, womp, it did not significantly improve blood pressure control compared to standard care. So both of those were bummers. Both of those were like, nah, it didn't really seem to do anything great. And so the take home was, well, I guess we're just not going to do that anymore. But everybody quickly pumped the brakes. Now remember, this was 2022. I love this guys. Look how this makes sense. This was in 2022. And so the fear was that we're all going to go, we're not going to do it anymore, we're just going to abandon that. That is called throwing the baby out with the bath water and no more home blood pressure monitoring. Whoa, whoa, whoa, Whoa. Come now 2023 with SMFM's console. I'm sorry, Console series. My brain. Sorry, guys, I, I literally, I'm behind caffeine. It's not a console series. It is a special statement in SMFM's special statement, Telemedicine in Obstetrics, March of 2023. You see how this works, guys? Timing is everything. Now, there are some things like from acog, that take forever to come out, trust me, because still working on something, it takes forever to go through approvals and internal review, legal review, yada, yada, committee review. But this was perfectly timed. Right after bump one and bump two, the Society of MFM special statement on telemedicine and obstetrics. Here's where we get this answer of why we should do this. There is a section on this. Again, I'm trying to be very quick here on prenatal visits and hypertension. So here it is and then we're going to wrap this up. So even though bump one and bump two were disappointing, the reason that we should keep doing it is very clear. Home blood pressure monitoring, HBPM has been endorsed in both national and international guidelines. Let's stop there for a minute. Ah, so it is a thing. Okay, so that was published. They're referencing a publication in circulation in 2020 and then a separate publication in the Journal of hypertension back in 2008. So we've got two different references, nearly a decade apart, well over a decade apart, both saying to do this right, with the most recent, of course, being in circulation 2020, in addition to ACOG's practice bulletin number 2, 222, which is gestational Hypertension in Pregnancy. That also came out in 2020. 2020 big for hypertension. 2020 big for hypertension.
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So home blood pressure monitoring has been endorsed in both national and international guidance. But now here it is. Okay, now here's where they're gonna say, hey, brace yourself, Susan. Brace yourself. I don't know why I said Susan. It's a weird morning. I. I don't know. Okay, brace yourself. Quote. However, the impact in hypertensive populations has been inconsistent. End quote. All right, so in other words, you got to read this in common Language, Right. We don't even know. The data is kind of complicated here. That's what they're trying to say. They go on, quote, because hypertensive disorders in pregnancy represent a leading cause of maternal morbidity and mortality. Yes, that is true. There are potentially substantial opportunities for telemedicine within this population. In other words, they're saying, look, the data may be gray, but significant maternal morbidity SMM is a big deal. So we've got to do something here. Even though the data is kind of gray, this is an opportunity where telemedicine may play a role. And if you're doing telemedicine, that implies what? Ambulatory home monitoring. Now, here's where they get in specifically with the data in a meta analysis of nine trials in patients with hypertensive disorders in pregnancy who are at risk for. For hypertensive disorders. Okay, so this was. I'm sorry, it's both patients with a history of hypertensive disorders and those at risk for hypertensive disorders. A meta analysis of nine trials in patients with hypertensive disorders or at risk of hypertensive disorders. Here it is. Antenatal home blood pressure monitoring was associated with reduction in labor induction, prenatal hospital admission. Okay. And reduction in diagnosis of preeclampsia without adverse impact on composite maternal, fetal or neonatal outcome. What? So now hold on, because this is not. This has nothing to do with bump one and bump two. That study that they're referencing, this meta analysis of nine trials was. Was published in pregnancy hypertension. Guess what year. I mean, it's. It's like a joke, right? I mean, no joke, guys. It is in 2020. I told you, 2020. Big we. In 2020, we had all this data coming out in terms of hypertension with pregnancy. It's just like man. So out of pregnancy and hypertension in 2020. Yes, there was a systematic review and meta analysis of nine trials that said, look, it decreased labor induction, decreased admission, decreased diagnosis of preeclampsia. Notice those were all decreased. Do you all get this? Bump one was looking for an increase. You follow this in the diagnosis of gestational hypertension or preeclampsia in those at risk. And then bump two looked for an increase, in other words, catching it early of disease, deterioration in chronic or gestational. Do you see how these are two different things? Is that amazing or what? So the first answer I would have given as an attending to that answer is, well, number one, sometimes evidence based data is everything. Clinical, standard of care. And that's the way it is. Number two is because they're looking at different things. There is a published systematic review and meta analysis out of 2020 in pregnancy hypertension that found that it reduced admissions, it reduced induction without any adverse perinatal issues, whereas Bump one and Bump two were looking for increase in diagnoses. Wow. Okay, so this, they're looking at totally different things. So is there data for home blood pressure monitoring? Absolutely. And this systematic review and Meta analysis from 2020 proves that. However, right after that, here it is, they get into bump one and bump two. So they're being very transparent. Remember 2023, that's not long ago, guys, because we're doing this, remember, basically mid-2026. Now, here's what SMFM says about bump one and bump two. Despite these encouraging results from smaller studies, a large randomized trial of patients with chronic or gestational hypertension, y', all, that's Bump two, failed to demonstrate that antepartum home blood pressure monitoring resulted in any improvement in blood pressure control or obstetrical outcome compared with usual antenatal care. Alright, so they're not hiding it. They're like, yeah, conflicted. Then they go on to say another large randomized trial of home blood pressure monitoring versus usual care in patients at risk of preeclampsia. That is Bump one also found no difference in the rates of diagnosis of preeclampsia, development of hypertension or other maternal or perinatal outcome. End quote. So there it is. This is an SMFM's special statement. So that's tending. Ideally would have read this and gone, oh yeah, yeah, you know what, it makes sense. There is conflicted data where bump one and Bump two did not show a benefit. They are correct. But that's missing the other data. That is smaller trials based on meta analyses and systematic review that said, hey, while one looked to increase diagnosis and we actually decrease some other admissions, so they both kind of wash out in the wash. And even though those data are dichotomally opposite. Boy, English is a second language. You know what I'm talking about? Dichotomous. Two different things. That's the word, Michael. Dichotomous. They are dichotomous results. Bump one and Bump two. Nothing good. These other trials. Yeah, something good. What we meet in the middle is this. And here's the last answer and then we're done. Remember the intro? I said that the two words here, guys, where this comes into play very easy. And this would have, would have answered. My answer would have been to the Resident. As a final kind of seal, the bow in the box is while the data is conflicted and while standard of care can sometimes not look exactly like what the published evidence shows, the reality is, is that it is a quote, additional safety net. Those are the two words, safety net, additional safety net for patients. Because in reality, well outside of a clinical trial, which is not necessarily reality, it's very governed, very controlled. In reality, in day to day practice, when patients miss appointments, there is transportation issues, there's daily stressors, there's socioeconomic, environmental triggers. This is where home blood pressure monitoring plays a role because it is extra pair of eyes that we don't have. So the reason we do it is because it is an additional layer of safety, knowing that the data is conflicted. But it also, and most importantly gives patients buy in into their care and invest them as a partnership. And I know that's touchy feely and I don't really do that. I like, you know, black and white clinical evidence. But even that is in the SMFM special statement where it talks about patient satisfaction and partnership. It's right there. By having patients do this home blood pressure monitoring gets them a buy in in their care and they're more aware not just of their blood pressure but of overall symptomatology. So yes, it is absolutely still recommended to do home blood pressure monitoring. Even though bump one and bump two as large respected, very well acknowledged, randomized trials didn't show any benefit, but they were looking at progression of disease. The benefit seems to be in reduction of admissions and reduction potentially of hospital stays without adversely affecting OB and perinatal outcomes. How about that? So there is an answer. So to this resident, what a deep, deep, beautiful, brilliant, complex question. If bump one and bump two didn't show any benefit, why are we still doing home blood pressure home monitoring? And the answer is, number one, standard of care sometimes is different from evidence based practice when the data is conflicted. Number two, there is in fact data on this, but it depends on what your endpoint you're looking at. If it's looking to catch disease getting worse, that's not really found. But if it's looking to make sure that you can reduce some interventions, that may be possible. Okay, so that's the win there. And then number three is that it is. And here's the big one, a patient safety net and buy in into their care. This is a nice reference out of March 2023 from SMFM's Special Statement podcast Family. As always, we're thankful for you. We're glad you're part of our podcast community. And now that we have done all that. And my blood pressure is up. Michael, let's take it home. This is Dr. Chapma's OB GYN no Spin podcast. It.