Severe Hypertension In Pregnancy Research Articles

Relationship between the hemodynamic profile and resistant hypertension in pregnant patients with hypertensive crisis

ABSTRACTObjectiveReducing maternal morbidity and mortality has been a challenge for low and middle-income countries, especially in the setting of hypertensive disorders of pregnancy. Improved strategies for treating obstetric patients with resistant hypertension are needed. We sought to explore whether hemodynamic parameters may be used to identify patients that develop resistant hypertension in pregnancy.MethodsRetrospective cohort study among pregnant patients with gestational hypertension or preeclampsia that experienced severe blood pressure elevations. Hemodynamic variables were evaluated, including cardiac output (CO), and total peripheral resistance (TPR). The primary endpoint was resistant hypertension. An exploratory logistic regression was performed to evaluate the association between the hemodynamic profile and the development of resistant hypertension. Adverse maternal and fetal outcomes were additionally described according to the presence of resistant hypertension.ResultsFifty-seven patients with severe pregnancy hypertension were included, of whom 34 developed resistant hypertension (59.7%). The resistant hypertension group, in comparison to those without resistant hypertension, presented with a hypodynamic profile characterized by reduced CO < 5 L/min (41.2% vs. 8.7%, p: 0.007), and increased TPR > 1400 dyn-s/cm5 (64.7% vs. 39.1%, p: 0.057). Logistic regression analysis revealed an association between a hypodynamic profile and resistant hypertension (OR 3.252, 95% CI 1.079–9.804; p = 0.035). Newborns of the resistant hypertension group had more frequent low birth weight (<2500 g), low Apgar scores, ICU admissions, and acute respiratory distress syndrome.ConclusionPatients experiencing hypertensive crisis during pregnancy and exhibiting a hypodynamic profile (TPR ≥1400 dyn·s/cm5 and CO ≤ 5 L/min) developed higher rates of resistant hypertension.

Oral Nifedipine Versus Intravenous Labetalol for Hypertensive Emergencies During Pregnancy: A Systematic Review and Meta-analysis

(Abstracted from J Matern Fetal Neonatal Med 2023;36(2):2235057) Hypertensive disorders of pregnancy are a leading cause of maternal and perinatal death. Severe pregnancy hypertension is defined as 160/110 mm Hg.

Physiologic Treatment of Severe Hypertension in Pregnancy and Postpartum.

We aimed to evaluate physiologic treatment of severe hypertension. This was a retrospective cohort study of pregnant and postpartum patients with severe hypertension (systolic blood pressure [BP] 160 mm Hg or higher or diastolic BP 110 mm Hg or higher) treated with intravenous labetalol or hydralazine at a single tertiary care center between 2013 and 2018. Patients were classified as having physiologic treatment if they had hyperdynamic physiology (pulse pressure 65 mm Hg or higher) and received labetalol or had vasoconstrictive physiology (diastolic BP 100 mm Hg or higher) and received hydralazine. The primary outcome was number of antihypertensive doses to achieve nonsevere BP. Of 1,120 patients included in the analysis, 653 had physiologic treatment and 467 had nonphysiologic treatment, with 16 (1.4%) excluded for inability to classify physiology. Physiologic treatment was associated with fewer antihypertensive doses (1.4±0.9 doses vs 1.6±1.4 doses; adjusted β -0.28, 95% CI, -0.42 to -0.14) and lower odds of medication conversion (2.5% vs 4.7%; adjusted odds ratio 0.48, 95% CI, 0.24-0.93) but no difference in time to nonsevere BP (31 minutes [interquartile range 16-66 minutes] vs 34 minutes [interquartile range 15-76 minutes]; adjusted hazard ratio 1.0, 95% CI, 0.9-1.2). Physiologic treatment of severe hypertension warrants further evaluation.

The Ohio Maternal Safety Quality Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented during the COVID-19 pandemic

Hypertensive disorders of pregnancy are a leading cause of severe maternal morbidity (SMM) and mortality and studies have shown that more than 60% of cases are preventable. As part of a state-wide quality maternal safety quality improvement project (MSQIP), we adapted the Alliance for Innovation on Maternal Health (AIM) Severe Hypertension in Pregnancy bundle in a consortium of maternity hospitals in [REDACTED] to improve care processes and outcomes for patients with a severe hypertensive event during pregnancy or postpartum period. To report the first year of data from this MSQIP, including an assessment of the process measures by hospital level of maternal care designation, and provide perspective on the unique challenges of implementing a large-scale MSQIP during a global pandemic. This MSQIP engaged [REDACTED] Level I-IV maternity hospitals and provided multimodal QI support. Participating hospitals submitted monthly patient level data, which included all cases of new onset sustained severe hypertension. The primary process measure was the proportion of birthing persons in [REDACTED] with sustained severe hypertension who received treatment with appropriate acute antihypertensive therapy within 60 minutes. Secondary process measures included receipt of: a follow-up appointment after hospital discharge within 72 hours (if discharged on medication) or 10 days (if discharged without medication), a blood pressure cuff on hospital discharge, and education about urgent maternal warning signs. Data for primary and secondary process measures were plotted on a biweekly basis and statistical process control methods were used to identify special cause variation over time. Data were stratified by various demographic variables, including race/ethnicity, insurance status, and maternal level of care. To assess the impact of the COVID-19 pandemic on this MSQIP, process measure data was compared to COVID-19 case volume in [REDACTED] across the study epoch. Twenty-nine hospitals participated in the project from July 2020 through September 2021. Data was collected on 4,948 hypertensive events representing 4,678 unique patients. In aggregate, the primary process measure (timely and appropriate treatment) demonstrated a 19.3% increase (from baseline of 56.5% to 67.4%, p < 0.001). The secondary process measures demonstrated significant increases ranging 26.1% to 166.8% (all p < 0.001). Both non-Hispanic Black and White pregnant or postpartum people demonstrated shifts and sustained improvements in the treatment of severe hypertension, which did not differ by race across the study period. Notably, process measure improvements were achieved and sustained across peaks in the COVID-19 pandemic. This [REDACTED] MSQIP demonstrated meaningful changes in project process measures in the identification and treatment of severe hypertension in pregnancy and the postpartum period. Process measures improvements were achieved across all hospital levels of maternal care and differences were not observed by race or ethnicity. Our findings suggest that a robust and comprehensive QI initiative with appropriate support and resources can achieve meaningful gains in the setting of a global pandemic.

Identifying Targets to Improve the Management of Severe Hypertension in Pregnancy and Postpartum

ObjectivesTo (1) define quality indicators, (2) describe care gaps, and (3) identify process issues in severe hypertension (sustained systolic blood pressure [BP] ≥160 mm Hg or diastolic BP ≥110 mm Hg) management at our tertiary care centre. MethodsPregnant and postpartum persons diagnosed with a hypertensive disorder of pregnancy from 2018 to 2019 were identified. A retrospective cohort of patients with severe hypertension was constructed, and data were collected through chart review. Severe hypertension management was assessed according to defined quality indicators. Clinical characteristics were compared between participants with and without time-to-target BP within 60 minutes. Process issues were examined for each severe hypertension occurrence. ResultsOf 608 participants with a hypertensive disorder of pregnancy, 90 (15%) experienced severe hypertension. Median time-to-target BP was 76 minutes (interquartile range 47–123 minutes), and target BP (<155/105 mm Hg) was achieved within 60 minutes in 31/90 (34%) participants. Appropriate antihypertensives for severe hypertension were used in 55/90 (61%), and time-to-treatment initiation was within 30 minutes in 42/54 (78%). Chronic hypertension and oral labetalol use were associated with delays in achieving target BP. Process issues related to severe hypertension management included inappropriate treatment (n = 35/90; 39%), failure to recognize severe hypertension as an emergency (n = 21/90; 23%), and delayed treatment initiation (n = 12/54; 22%). ConclusionWe defined quality indicators for severe hypertension management. Time-to-target BP within 60 minutes was achieved in a minority of patients, and chronic hypertension was associated with delayed severe hypertension resolution. Process issues in severe hypertension management were described.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Impact of maternal early warning system and safety bundle on timely treatment of severe hypertension

To evaluate the impact of quality improvement (QI) and patient safety (PS) initiatives on timely treatment of severe hypertension (SHTN) in pregnancy. Retrospective chart review of all hospital deliveries between January 1, 2016 through June 30, 2022 with an episode of SHTN. During the study time period, our hospital implemented a maternal early warning system (MEWS), which mandated provider bedside evaluation for SHTN, and a patient safety bundle on SHTN in pregnancy that included team-based simulations around a new hospital guideline. Timely treatment of severe hypertension was defined as the percent of patients during their delivery hospitalization who received an antihypertensive agent within 60 minutes of the first documented severe blood pressure if it persisted for at least 15 minutes. Acceptable antihypertensive agents included intravenous labetalol or hydralazine or immediate release oral nifedipine. All deliveries ≥ 20 0/7 weeks were included. Data was analyzed using chi-square analysis. During the study period, there were 464 patients that met inclusion criteria prior to MEWS (phase 1), 1009 after MEWS (phase 2), and 375 with MEWS+bundle (phase 3). There was a statistically significant improvement in the rate of timely treatment of SHTN with implementation of MEWS (25.9% in phase 1 vs 44.0% in phase 2, p< .001) and then again with the bundle (61.3% in phase 3, p< .001 compared to phase 2). When looking at the data by race and ethnicity, non-Hispanic (NH) White patients were less likely to receive timely treatment as compared to NH-Black patients during phases 1 and 2, with elimination of this disparity in phase 3 (p < .001, p = .04, p = .42, respectively). Compared to NH-White patients, Hispanic patients were less likely to receive timely treatment during phase 2 only (p = .04). QI/PS efforts that standardize response to and treatment of SHTN can lead to improvement in timely treatment and elimination of disparities, which may in turn reduce severe maternal morbidity and mortality from hypertensive disorders of pregnancy.

S-10-2: OPTIMAL BLOOD PRESSURE TARGET TO PREVENT SEVERE HYPERTENSION IN PREGNANCY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: Severe hypertension in pregnancy is a hypertensive crisis that requires urgent and intensive care due to its high maternal and fetal mortality. However, there still remain some discrepancies between guidelines in a target blood pressure to prevent severe hypertension in pregnancy. This study aimed to find the optimal blood pressure (BP) levels to prevent severe hypertension in pregnant women with nonsevere hypertension. Design and method: We searched Ovid MEDLINE and the Cochrane Library to identify all randomized controlled trials, which compared effects of antihypertensive drugs and placebo/no treatment or more intensive and less intensive BP-lowering treatments on adverse maternal and fetal pregnancy outcomes among pregnant women with nonsevere hypertension. A random effects model meta-analysis was performed to estimate the pooled risk ratio (RR) and 95% confidence interval (CI) for the outcomes. Results: Forty RCTs with 6355 patients were included in this study. BP lowering treatment significantly prevented severe hypertension (RR, 0.46; 95% CI, 0.37 to 0.56), preeclampsia (RR, 0.82; 95% CI, 0.69 to 0.98), severe preeclampsia (RR, 0.38; 95% CI, 0.17 to 0.84), placental abruption (RR, 0.52; 95% CI, 0.32 to 0.86), and preterm birth (before 37 weeks; RR, 0.81; 95% CI, 0.71 to 0.93), while the risk of small for gestational age infants was increased (RR, 1.25; 95% CI, 1.02 to 1.54). An achieved systolic blood pressure (SBP) of lower than 130 mmHg reduced the risk of severe hypertension to nearly one-third compared with an achieved SBP of 140 mmHg or higher, with a significant interaction of the BP levels achieved with BP lowering therapy. There was no significant interaction between BP lowering treatment and the subtypes of hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, and chronic hypertension. Conclusions: BP lowering treatment aimed at a SBP of lower than 130 mmHg and accompanied by careful monitoring of fetal growth might be recommended to prevent severe hypertension among pregnant women with nonsevere hypertension.

Comparison of Intravenous Anti-hypertensives for Preoperative Blood Pressure Control in Hypertensive Disorders of Pregnancy and Effect of Oral Labetalol.

Intravenous hydralazine and labetalol are recommended as first-line anti-hypertensives for controlling severe hypertension in pregnancy. Our study aimed at identifying the most effective drug with minimum side effects for preoperative management of severe hypertension in parturients scheduled for Caesarean delivery (CD). We also studied the effect of these drugs on patients already on oral labetalol in the antenatal period. A prospective observational study was done on 162 hypertensive parturients scheduled to undergo emergency CD who received hydralazine or labetalol in the preoperative period. Demographic data, booking status, hemodynamic data, time taken to reach adequate control of blood pressure (BP), drug efficacy, the incidence of persistent hypertension, adverse effects associated with the drugs, and maternal and fetal outcomes were noted. The time taken for the control of BP was similar with both drugs (p-value = 0.425). The mean number of doses required to achieve target BP was significantly less with hydralazine compared to labetalol (p-value = 0.009). Patients on tablet labetalol in the antenatal period were poorly controlled when put on the same drug intravenously but had better control with hydralazine (p-value = 0.005). The incidence of persistent hypertension was lower in patients treated with hydralazine compared with labetalol (p-value = 0.008). Both drugs took a similar time for BP control. However, hydralazine was more efficacious, produced adequate control of BP in a higher number of patients, and had a lower incidence of persistent hypertension.

Comparison of relaxant effects of nifedipine and NS11021 on isolated umbilical arteries of healthy and preeclamptic pregnant women

ObjectivesPotassium (K+) channel openers and calcium (Ca2+) channel blockers are currently used to treat acute severe hypertension in pregnancy. We aimed to investigate the vasorelaxant effect of NS11021, a potent and specific big-conductance Ca2+-activated K+ (BKCa) channel activator, and to compare it with the vasorelaxant effect of nifedipine on human umbilical arteries (HUAs) isolated from healthy and preeclamptic pregnants. Study designA total of 29 HUAs were isolated immediately after delivery from 14 healthy and 15 preeclamptic pregnant with severe features. The concentration-dependent relaxation responses were obtained to nifedipine and NS11021 on HUAs precontracted with endothelin-1 (ET-1) (10-8 M) in an isolated tissue bath. ResultsBoth nifedipine and NS11021 caused concentration-dependent relaxation responses in HUAs from healthy and preeclamptic pregnants. While the maximum responses (Emax) and pD2 values of nifedipine did not change significantly in both groups, the Emax and pD2 values of NS11021 were significantly decreased in the preeclampsia group (Emax ± SEM; %75.57 ± 4.53 and %43.75 ± 14.00 and pD2 ± SEM; 6.92 ± 0.26 and 5.24 ± 0.53 respectively, p < 0.05). In addition, the pD2 value of NS11021 was not significantly different from that of nifedipine in the control group, but decreased significantly in the preeclampsia group (pD2 ± SEM 7.1 ± 0.41 and 5.2 ± 0.53, p < 0.05, respectively). ConclusionsEfficacy and potency of NS11021 decreased in HUAs from preeclamptic pregnants. Also, NS11021 is less potent than nifedipine in the preeclampsia group. BKCa channels may have a role in the pathogenesis of preeclampsia, however, further experimental studies are needed to elucidate that.

Improving treatment of severe hypertension in pregnancy and postpartum using a hypertensive pathway.

To assess the implementation of an antihypertensive pathway order set to improve treatment of severe hypertension in pregnancy and the postpartum period in the inpatient setting. A multi-disciplinary task force created a hypertensive pathway order set and provided staff training. The order set allowed providers to initiate a treatment algorithm, which then gave nurses guidelines to recheck blood pressures and progressively increase short-acting antihypertensive dosage if needed. Pregnant and postpartum patients documented to have ≥2 consecutive severe range blood pressures in the year prior (2017) and the year after (2019) implementation of the pathway were included. Primary outcomes included whether any antihypertensive was given, whether it was given for all instances of severe hypertension, and time to antihypertensive administration. A total of 566 patients with severe hypertension were included-304 in the pre-implementation year and 262 in the post-implementation year. Significantly more patients received an antihypertensive at least once (67% versus 80%, p<0.01) and for all instances of severe hypertension (29% versus 47%, p<0.01) in the post-intervention cohort. There was a significant improvement in time to antihypertensive administration (24 versus 10min, p<0.01). This study evaluates the efficacy of an antihypertensive intervention in the Southeast United States, which is particularly significant given the region's higher rates of hypertension and hypertension-related mortality. This study provides confirmatory evidence that implementation of a standardized order set along with measuring compliance and staff education is associated with improved treatment rates and time to treatment administration.

Severe preeclampsia superimposed on secondary and resistant hypertension associated with methamphetamine use

Introduction: Preeclampsia (PE) is one of the three main causes of maternal mortality. It is called superimposed PE when, in a pregnant patient with a history of primary or secondary chronic arterial hypertension, blood pressure increases and de novo proteinuria appears or worsens and/or biochemical data such as thrombocytopenia or increased liver enzymes are added. Chronic arterial hypertension predisposes patients to developing it, with a higher risk of complications and severity. Case presentation: Here, we present the case of a 25-year-old patient with a history of crystal, crack, and cocaine use for 7 years and a diagnosis of high blood pressure since she was 22 years old, who developed severe PE resistant to antihypertensive drugs. Conclusions: The reported case showed severe hypertension in pregnancy (defined as systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg), which persisted because severe hypertension continued despite the designated treatment, which, considering the patient’s age, forced us to suspect secondary hypertension. The incidence of secondary hypertension in patients with superimposed PE is rare. According to the American Heart Association, it occurs in 10% of the cases and is associated with greater maternal and fetal complications. This should be suspected in women &lt;35 years of age with severe or resistant hypertension, without a family history of hypertension, or with biochemical parameters for hypokalemia, hyperazotemia, and albuminuria in the early stages of pregnancy.

Abstract 14095: Factors Influencing Timely Recognition and Treatment of Severe Hypertension in Pregnancy

Background: Severe hypertension is an obstetric emergency. Timely identification and management can reduce risk of serious events. Aims of our study were to 1)assess whether severe hypertension is being recognized and managed within the recommended time frame and 2)evaluate the factors that are associated with timely identification and treatment of severe maternal hypertension. Methods: A retrospective study of pregnant and postpartum women presenting with severe hypertension to tertiary care hospital between 1/1/19 to 12/1/19. Main outcome measures were ‘time to repeat blood pressure check(TTC)’ and ‘time interval between confirmation of severe hypertension and initiation of pharmacotherapy(TTT)’. We examined the association of the type of hospital unit, time of day of presentation and race/ethnicity with the outcome measures. Results: A total of 656 women were included in the study. Median time for repeat blood pressure check was 16 minutes. Only 46.2% of women had a repeat blood pressure check within 15 minutes. Median interval between confirmation of severe hypertension and initiation of therapy was 38.5 minutes. 63.3% of women were treated within the recommended time frame of 60 minutes. Both timely blood pressure re-check(15.6% vs 51.4%, p &lt; 0.001) and initiation of treatment(38.5% vs 70.8%, p &lt; 0.001) were significantly lower in the emergency department (ED). TTC(57.9% vs 31.4%, p &lt; 0.001) and TTT(86.4% vs 42%, p &lt; 0.001) were significantly better in the labor and delivery unit. Time of day(day 51.6% vs night 57.3%, p = 0.15) and race/ethnicity(black 57.1% vs non-black 51.6%, p = 0.16) were not associated with delay in repeat blood pressure check. However, black race(46.2% vs 28.6%, p = 0.018) was associated with delayed initiation of therapy compared to non-black patients. Conclusions: We found both the rates of timely identification and treatment of severe maternal hypertension in the ED were lower compared to other units. This points to need for continuous education of ED healthcare providers about timely recognition and management of severe maternal hypertension. We also found racial disparities in timely initiation of therapy, thus demonstrating the need for standardization of protocols.

Comparison of intravenous labetalol and hydralazine for severe hypertension in pregnancy in Northeastern Nigeria: A randomized controlled trial.

The objectives were to compare the efficacy and safety of intravenous hydralazine and labetalol for acutely lowering severe hypertension in pregnancy. This was a superiority parallel double-blinded randomized controlled trial conducted from October 2018 to June 2019 in two hospitals in Gombe, Nigeria. Pregnant women with a live singleton fetus at gestational age of at least 28weeks with severe hypertension were randomized (60 per group) to receive incremental doses of either intravenous labetalol (20mg; 40mg; 80mg; 80mg; and 80mg) or 10mg of intravenous hydralazine - up to a maximum of 5 doses - until the target blood pressure was achieved or the study was terminated. The main outcome measures were the mean reduction in mean arterial blood pressure and occurrence of persistent hypertension. Other endpoints were maternal side-effects, perinatal death, Apgar score at birth and SCBU admission. One hundred and thirteen patients' data were analyzed (fifty-six [56] in the hydralazine group and fifty-seven [57] in the labetalol group). There were no significant differences in the fall of the mean arterial blood pressure (labetalol; 24.19mmHg/hydralazine; 27.68mmHg) (p=0.192), maternal side effects, perinatal deaths, Apgar scores and SCBU admission between the two groups. Hydralazine, however, produced a more marked reduction in diastolic blood pressure than labetalol (p=0.012). Both labetalol and hydralazine are effective for acute blood pressure control in pregnancy with a similar safety profile. This study was self-funded and registered in the Pan African Clinical Trials Registry (www.pactr.orgPACTR202010738538062).

Nonadherence to treatment protocol for severe hypertension in pregnancy

Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality and severe morbidity. The American College of Obstetricians and Gynecologists recommends treatment of persistent severe hypertension because this has been shown to improve overall outcomes. Treatment remains inconsistent and may be influenced by patient-level sociodemographic and clinical characteristics. This study aimed to identify which factors are associated with nonadherence to an institutional protocol for the treatment of severe hypertension in pregnancy. Retrospective cohort study of patients who had persistent severe hypertension (≥2 systolic blood pressures ≥160 mm Hg and/or diastolic blood pressures >110 mm Hg between 15 and 60 minutes apart) during their delivery hospitalization in 3 hospitals within an integrated health system from February 1, 2018 to March 1, 2020. Adherence to an institutional protocol was defined as receiving antihypertensive medication within 1 hour of a second severe blood pressure measurement. Demographic information, medical comorbidities, and delivery hospitalization characteristics were compared between women who received treatment based on institutional protocol and those who did not. Patient zone improvement plan codes were linked to neighborhood-level data from the US Census Bureau's American Community Survey to extract socioeconomic characteristics. A multivariable logistic regression was performed to evaluate factors associated with delayed treatment while adjusting for potential confounders. Of the 996 patients included, 449 (45%) received treatment within 60 minutes and 547 (55%) did not. Having an elevated, nonsevere range blood pressure (adjusted odds ratio, 0.55; 95% confidence interval, 0.38-0.79) or a severe range blood pressure (adjusted odds ratio, 0.25; 95% confidence interval, 0.16-0.38) on admission, persistent severe hypertension ≥1 hour before or after delivery (adjusted odds ratio, 0.27; 95% confidence interval, 0.27-0.45), and chronic hypertension (adjusted odds ratio, 0.58; 95% confidence interval, 0.37-0.93) were associated with timely treatment. Hospital site (adjusted odds ratio, 1.97; 95% confidence interval, 1.18-3.28) and increasing gestational age (adjusted odds ratio, 1.14; 95% confidence interval, 1.07-1.21) were associated with nonadherence to treatment protocol. A subanalysis evaluating treatment in 344 (35%) patients who had a nonelevated blood pressure on admission showed that White race, persistent severe hypertension within 1 hour of delivery, increasing gestational age, body mass index, twin gestation, preferred language other than English or Spanish, and a higher neighborhood unemployment rate were associated with nonadherence to treatment protocol. Several factors were associated with nonadherence to an institutional protocol for treatment of persistent severe hypertension. Provider bias may impact whether treatment is executed or not. Awareness of these risk factors may improve timely administration of antihypertensive medication in pregnant and postpartum patients.

How to Improve Care of Obstetric Patients With Severe Hypertension in the Emergency Department

Despite implementing the Alliance for Innovation on Maternal Health (AIM) patient-safety bundle for severe hypertension in pregnancy, hospitals continue to struggle to engage the emergency department in appreciating the care bundle strategies. There appears to be a lack of knowledge and, thus, a failure to recognize severe hypertension in obstetric patients and the implications of severe morbidity and mortality this failure can cause.

Efficacy of Labelol and Magnesium Sulfate in Severe Pregnancy Hypertension and Its Effect on Delivery Outcome

Efficacy of Labelol and Magnesium Sulfate in Severe Pregnancy Hypertension and Its Effect on Delivery Outcome

Nicardipine for treating severe antepartum hypertension during pregnancy: Nine years of experience in more than 800 women.

Women with severe hypertension during pregnancy require prompt stabilization with a combination of magnesium sulfate and rapidly acting intravenously administered antihypertensives. It remains unknown which antihypertensive is best suited for pregnancy. The present study evaluated the intravenous use of the calcium antagonist, nicardipine. This multicenter, retrospective case series included all pregnant women beyond 20 weeks of gestation with severe antepartum hypertension that were treated with intravenous nicardipine. successful treatment, time to successful treatment, and maternal safety. Severe hypertension was defined as systolic blood pressure (SBP) of 160 mm Hg or more and/or diastolic blood pressure (DBP) of 110 mm Hg or more. This study included 830 women. After 1 h of treatment, two-thirds of the women had SBP below 160 mm Hg and DBP below 100 mm Hg. In three out of four women, the mean arterial pressure was below 120 mm Hg. Within 2 h of treatment, 77.4% of women achieved successful treatment. In all cases, nicardipine was eventually effective. Within the first 2 h, 42.7% of women experienced temporary low DBP (ie below 70 mm Hg) without clinical consequences for the mother or fetus. In all cases, the low DBP resolved after discontinuing or reducing the dosage of nicardipine. One case of fetal distress was attributable to maternal hypotension, and a cesarean section was performed at more than 2 h after initiating therapy. During treatment, headache, nausea, and vomiting decreased significantly. To date, this was the largest case-series study on the use of nicardipine for treating severe antepartum hypertension in pregnancy. We found that nicardipine could effectively and safely treat this condition. Based on its high success rate and acceptable safety profile, nicardipine should be considered a first-line treatment in women with severe hypertension in pregnancy.

Impact of implementation of the Maternal-Fetal Triage Index on patients presenting with severe hypertension

Severe hypertension remains one of the leading preventable causes of maternal mortality in the United States. Timeliness to response to severe hypertension in pregnancy is a crucial quality indicator tracked by state and national organizations. We hypothesized that the implementation of the Maternal-Fetal Triage Index, a validated acuity tool, would improve care performance in women with severe hypertension in an urban, inner-city hospital setting. This study aimed to assess the impact of the Maternal-Fetal Triage Index on the management of women presenting with severe preeclampsia diagnosed by severe hypertension as measured by time to provider assessment, administration of magnesium sulfate, and immediate administration of acute antihypertensives. This was a prospective, observational study of pregnant women presenting to the labor and delivery triage unit with severe preeclampsia diagnosed by severe hypertension giving birth at a large urban inner-city academic facility before (epoch 1: January 1, 2019, to December 31, 2019) and after (epoch 2: March 1, 2021, to September 31, 2021) the implementation of the Maternal-Fetal Triage Index. Baseline outcomes of time to assessment, time to magnesium sulfate prophylaxis, and time to antihypertensive medication administration before the implementation of the Maternal-Fetal Triage Index were assessed. The Maternal-Fetal Triage Index tool was implemented on March 1, 2021, following standardized education in 2020 for all triage nurses, unit technicians, healthcare unit coordinators, and healthcare providers. Time to assessment, administration of magnesium sulfate prophylaxis, and time to antihypertensive administration after the implementation of the Maternal-Fetal Triage Index were compared with measures before the implementation of the Maternal-Fetal Triage Index. Statistical analysis included Wilcoxon rank-sum test with P<.05 considered significant when comparing epoch 1 with epoch2. A total of 370 patients were admitted with severe hypertension in 2019 before the use of the Maternal-Fetal Triage Index, and 254 patients were admitted with severe hypertension in 2021 after the implementation of the Maternal-Fetal Triage Index. There was no difference between epochs across baseline characteristics, including age, race and ethnicity, parity, and body mass index. After the Maternal-Fetal Triage Index was implemented, the time to provider assessment was significantly improved, from a median time of 44 minutes (interquartile range, 0-65) in epoch 1 to 17 minutes (interquartile range, 0-39) in epoch 2 (P<.001). Furthermore, the time from arrival to magnesium sulfate prophylaxis was significantly faster with a median time of 161 minutes (interquartile range, 109-256) in epoch 1 vs 127 minutes (interquartile range, 85-258) in epoch 2 (P=.001). Moreover, there was a decrease in the time from arrival to antihypertensive medication administration for severe blood pressures after the implementation of the Maternal-Fetal Triage Index (101 minutes [interquartile range, 61-177] vs 66 minutes [interquartile range, 35-203]; P<.001). The implementation of the Maternal-Fetal Triage Index at a large urban inner-city hospital was associated with improved timeliness of assessment and treatment of women with severe hypertension. The Maternal-Fetal Triage Index is a viable tool to improve the efficiency in triage units, specifically in the management of severe hypertension.

Lactate Dehydrogenase Enzyme Level in Women with Severe Preeclampsia: A Cross-sectional Study

Aim: To determine the frequency of raised lactate dehydrogenase enzyme in women with severe preeclampsia.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration: Obstetrics and Gynecology department at Liaquat University Hospital Hyderabad from June 2018 to December 2018.&#x0D; Methodology: There were 141 primiparous women with severe preeclampsia, included in this study. After taking history regarding hypertension and obstetrical examination, patients were subjected to a relevant investigation that is, 5ml of blood sent to an institutional laboratory for the measurement of lactate dehydrogenase enzyme, if it is &gt;400 U/L then it was labeled as raised.&#x0D; Results: The frequency of raised lactate dehydrogenase enzyme (400 U/L) was 13.48% (19/141) women with severe preeclampsia.&#x0D; Conclusion: About 14% of women having Pre-eclampsia had raised lactate dehydrogenase enzyme. Severe preeclampsia is associated with severe multisystemic involvement. Raised LDH levels are indicative of cellular damage and severe hypertension in pregnancy.