Severe Range Blood Pressures Research Articles

Treating Mild Chronic Hypertension During Pregnancy: A Cost-Effectiveness Analysis.

To assess the cost effectiveness of targeting a blood pressure of less than 140/90 mm Hg compared with 160/105 mm Hg. A decision-analytic model was constructed to compare the treatment of chronic hypertension in pregnancy at mild-range blood pressures (140/90 mm Hg) with the treatment of chronic hypertension before 20 weeks of gestation at severe-range blood pressures (160/105 mm Hg) in a theoretical cohort of 180,000 patients with mild chronic hypertension. Probabilities, costs, and utilities were derived from literature and varied in sensitivity analyses. Primary outcomes included incremental cost per quality-adjusted life-year (QALY), cases of preeclampsia, preeclampsia with severe features, severe maternal morbidity (SMM), preterm birth, maternal death, neonatal death, and neurodevelopmental delay. The cost-effectiveness threshold was $100,000 per QALY. Treating chronic hypertension in a population of 180,000 pregnant persons at mild-range blood pressures, compared with severe-range blood pressures, resulted in 14,177 fewer cases of preeclampsia (43,953 vs 58,130), 11,835 of which were cases of preeclampsia with severe features (40,530 vs 52,365). This led to 817 fewer cases of SMM (4,375 vs 5,192), and 18 fewer cases of maternal death (102 vs 120). Treating at a lower threshold also resulted in 8,078 fewer cases of preterm birth (22,000 vs 30,078), which led to 26 fewer neonatal deaths (276 vs 302) and 157 fewer cases of neurodevelopmental delay (661 vs 818). Overall, treating chronic hypertension at a lower threshold was a dominant strategy that resulted in decreased costs of $600 million and increased effectiveness of 12,852 QALYs. Treating chronic hypertension at a threshold of mild-range blood pressures is a dominant (lower costs, better outcomes) and cost-effective strategy that results in fewer neonatal and maternal deaths compared with the standard treatment of treating at severe range blood pressures.

Implementation of a nurse-driven protocol to improve recognition and response to severe range blood pressures

Implementation of a nurse-driven protocol to improve recognition and response to severe range blood pressures

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.

1044 Modifiable factors in the treatment of severe postpartum hypertension

We sought to determine whether Time to Treatment (TTT) and Time to Resolution (TTR) of severe hypertension varies by shift and nurse to patient ratio in our postpartum units. We performed a retrospective cohort study of patients delivered between 1/2017-9/2019 at Magee-Womens Hospital of the University of Pittsburgh Medical Center (UPMC). Women with 2 or more severe range blood pressures (BP) sustained ≥15 minutes in the postpartum period were identified utilizing data collected by UPMC’s Clinical Analytics Department. TTT was defined as the time from the first severe range BP to administration of the first rapid-acting antihypertensive agent. TTR was defined as the time from the first severe range BP to BP<150/100 mmHg. We performed a univariate analysis using Student’s T-Test and Wilcoxon Rank Sum test to compare TTT and TTR by postpartum unit (high-risk; nurse to patient ratio 1:2 versus routine; nurse to patient ratio 1:5 couplets) and shift (day; 7am-7pm versus night; 7pm-7am). 302 women met inclusion criteria. In all, 152 (50.5%) were treated with rapid-acting antihypertensives. Median TTT was significantly longer on routine postpartum units compared to high-risk postpartum units (57 minutes [IQR 40-98] vs. 38 minutes [IQR 27-70]; p=0.0004). Similarly, TTR was longer in routine units compared to high-risk units (149 minutes [IQR 103-274] vs. 80 minutes [IQR 45-150]; p<0.001). TTT in routine and high-risk units was similar during the day shift (47 minutes [IQR 37-94] vs. 48 minutes [IQR 28-80]; p=0.3), however, during the night shift, TTT was significantly longer on routine units compared to high-risk units (66 minutes [IQR 47-102] vs. 36 minutes [IQR 25-62]; p=0.001). Despite clear recommendation from ACOG on treatment of severe range blood pressures, only half of women in our cohort were treated with rapid-acting antihypertensives. We identified significant delays in treatment that were exacerbated by time of day. Complications from HDP are among the leading causes of preventable severe maternal morbidity and our data identified areas amenable to improvement.

1033 Racial disparities in the treatment of severe postpartum hypertension

Our objective was to determine if the time to treat (TTT) severe hypertension varied based on race on the inpatient postpartum units. We performed a retrospective cohort study of patients delivered between 1/2017-9/2019 at Magee-Womens Hospital of the University of Pittsburgh Medical Center (UPMC). Women with 2 or more severe range blood pressures (BP) sustained for ≥15 minutes in the postpartum period were identified utilizing data collected by UPMC’s Clinical Analytics Department. TTT was defined as the time from the first severe range BP to administration of the first rapid-acting antihypertensive agent. TTR was defined as the time from the first severe range BP to BP<150/100 mmHg. We performed a univariate analysis using Student’s T-Test and Wilcoxon Rank Sum test to compare TTT and TTR by self-reported race. 302 women met inclusion criteria: 103 women of Black race and 199 women of other races (predominantly White). Women of Black race were younger (29.2 (SD 6.7) vs 32.6 (SD 5.5) years, p <0.001), were less likely to be primiparous (39.8% vs 54.6%, p=0.02), and were more likely to have public insurance (84.3% vs 36.4%, p <0.001). The Non-Hispanic Black cohort trended toward more chronic hypertension and superimposed pre-eclampsia but this difference was not statistically significant, p=0.7. Of the total 302 women with sustained severe range BPs, only 50.5% were treated with rapid-acting antihypertensive. The median TTT in our Non-Hispanic Black cohort was 45 minutes (IQR 29-70) and 47 minutes (IQR 33-81) in our Other cohort, p=0.4. The median TTR in our Non-Hispanic Black cohort was 120 (IQR 50-202) and 109 (IQR 60-203) in our Other cohort, p=0.9. In our cohort, there was no difference in acute management of severe hypertension postpartum by race. however, only 50.5% of the sustained severe range blood pressures were treated with short-acting antihypertensives. These data suggest pathways to target for quality measures to improve management of postpartum hypertension.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

506 Factors associated with appropriate treatment of obstetric hypertensive emergency

We aimed to identify factors associated with receiving recommended treatment for obstetric hypertensive emergency. We present a retrospective case-control study of all women who had persistent severe hypertension (≥2 systolic blood pressures (BP) ≥160 mm Hg and/or diastolic BP ≥110 mm Hg within 1 hour of each other) during their delivery hospitalization at a tertiary hospital from 1/2013 to 9/2020. Data were extracted from hospital electronic medical records using standard definitions and billing and diagnosis codes. We defined recommended treatment as administration of intravenous labetalol or hydralazine, or oral immediate-release nifedipine any time after the first or second severe-range BP during their delivery hospitalization. Maternal age, race/ethnicity, marital status, insurance type, pre-pregnancy BMI, smoking status, parity, singleton versus multiple gestation, diabetes (pre-existing or gestational), hypertensive disorders of pregnancy (HDP), time of day (7am-6pm versus 7pm-6am) and day of week (weekday versus weekend) of hypertensive emergencies were compared between women who received recommended treatment and those who never received recommended treatment. Adjusted odds ratios (aOR) and 95% CI were calculated using multivariable regression analysis. Of 39,919 women, 2114 (5.3%) met inclusion criteria. 950 (44.9%) women received recommended treatment, while 1,164 (55%) did not. In the multivariate model, treated women were more likely than untreated women to be Black (aOR 1.51, 95% CI 1.17 – 1.95), have HDP (aOR 6.13, 95% CI 5.02 – 7.49) or have diabetes (aOR 1.45, 95% CI 1.43-1.85). Treatment was less likely if hypertensive emergency occurred overnight (aOR 0.70, 95% CI 0.57-0.86)(Table). Black race, HDP, diabetes, and daytime occurrence were associated with increased likelihood of receiving recommended treatment for obstetric hypertensive emergency. Severe hypertension overnight was associated with a 30% lower odds of receiving treatment, and could serve as a target for measures aimed at improving treatment and reducing maternal morbidity.

883 Racial disparities in utilization of oral anti-hypertensives in the postpartum period

Hypertensive disorders of pregnancy (HDP) carry disproportionate morbidity and mortality for black women particularly in the postpartum (PP) period. Currently, there are no standardized protocols for PP hypertension (HTN) other than standard recommendations to treat severe range blood pressures (≥160/110 mmHg). Our objective was to assess the proportion of women with persistent PP HTN treated with oral antihypertensive agents and to determine if this differs by race. We performed a retrospective cohort study that included women with a HDP (chronic HTN, superimposed preeclampsia, preeclampsia, eclampsia and gestational HTN) who delivered between 1/2017-9/2019 at Magee-Womens Hospital of the University of Pittsburgh Medical Center (UPMC). Our primary outcome was the proportion of women with persistent HTN discharged on an oral antihypertensive agent. Women were considered to have persistent HTN if they had 2 or more BPs of ≥150/100 mmHg at least 4 hours apart during the inpatient PP hospitalization. We identified eligible women utilizing data collected through UPMC’s Clinical Analytics Department. Demographic and obstetric outcomes were stratified by self-reported race. We identified 652 women diagnosed with a HDP with persistent PP HTN while inpatient; 215 (33%) black women and 437 (67%) women of other races. In all, 63% of women with HDP with persistent PP HTN were discharged on oral antihypertensive agents. There was no difference by race in the utilization of oral antihypertensives prior to discharge (62.3% of black women vs. 63.6% of other race, p=0.70). Among a subset of our cohort enrolled in a home BP management program (n=258), an additional 17.0% of women were initiated on oral anti-hypertensive agents after hospital discharge. Among women with persistent PP HTN, 63% were discharged on oral anti-hypertensive agents. In our cohort, use of oral antihypertensive medication during the inpatient PP hospitalization did not differ by race. Further investigation of appropriate BP parameters for initiation of oral antihypertensive agents in the PP period is needed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

33 Improving Treatment for Hypertensive Emergencies among Pregnant and Postpartum Women Using a Hypertensive Pathway Intervention

To assess the effect of an anti-hypertensive pathway order set in improving treatment of hypertensive emergency in pregnant and postpartum women A multi-disciplinary task force created a hypertensive pathway order set and provided staff training. Pregnant and postpartum women documented to have 2 or more consecutive severe range blood pressures (srBP) in the year prior (2017) and the year after (2019) implementation of the pathway were included. Use of short-acting antihypertensive (aHTN) (intravenous labetalol, intravenous hydralazine, or oral nifedipine) were considered appropriate treatment. Outcomes measured were whether aHTN was given at all, whether it was given for all instances of srBP, and time to aHTN administration. Rates of aHTN provision were compared before and after implementation of the standard order set. A total of 566 women with srBP were included, with 304 women in 2017 and 262 in 2019. There were no differences in age, parity, gestational age, race, or ethnicity between cohorts. There were more preeclampsia diagnoses in 2019 than 2017 (79% vs. 59%, p<0.01) (Table 1). The rates of aHTN administration improved significantly with use of the pathway—67% in the pre-intervention cohort received an aHTN at least once vs. 80% post-intervention (p<0.01) (Table 2). Significant improvement was also evident for receipt of aHTN for all instances of srBP (29% pre-intervention vs. 47% post-intervention, p<0.01). There was a significant decrease in time to administration of aHTN (39.7 minutes [SD=33.8] pre-intervention vs. 14.9 minutes [SD=20.7] post-intervention, p<0.01). There was an improvement in rates of and time to aHTN administration to pregnant and postpartum women after implementation of the hypertensive pathway, though rates did not approach 100%. These results are likely mediated by improved workflow, allowing greater nurse autonomy after a physician has initiated the pathway. There was also an increased rate of preeclampsia diagnosis in 2019, perhaps reflecting improved recognition. Future work will focus on cognitive aids for srBP recognition.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Evaluation of Implementation and Unit Impact of a Hypertensive Disorder of Pregnancy Guideline: A Model-Based Approach.

Hypertensive disorders of pregnancy are a leading cause of maternal mortality and morbidity. To address this, a large Midwestern hospital initiated a practice guideline. Practice guidelines should improve outcomes, but implementation of these remains challenging. At the time of initiation of the guideline, no implementation or evaluation plan was conceived. Evaluate the implementation and unit impact of a guideline for the management of hypertensive disorders of pregnancy in a large academic health system in the Midwest. Six objectives, guided by the constructs of the Ottawa Model of Research Utilization, were operationalized to evaluate the implementation and unit impact of the guideline. The guideline implemented was consistent with national recommendations. Intervention education was inconsistent across provider types. A survey of staff revealed insight into a unit in the midst of practice change. A chart review revealed below-target management of patients with severe range blood pressures. Not following the guideline was associated with hospital readmission. Guideline implementation can be efficiently and holistically evaluated with a model-based framework, even in projects that were not initiated with such an approach. Nurses provide expertise in model-based approaches that result in comprehensive evaluations of quality improvement processes.

Chronic hypertension in pregnancy: are outcomes the same in patients on antihypertensives?*

Objective To investigate differences in maternal and fetal outcomes among pregnant patients with chronic hypertension requiring antihypertensives for adequate control versus those who do not require antihypertensives. Study design Single-site retrospective cohort study including pregnant patients with chronic hypertension from 2015-2018. Two groups included those who required antihypertensives versus those who did not. Primary outcome is composite morbidity: pregnancy loss after 20 weeks, IUGR, maternal death, maternal stroke or TIA, pulmonary edema, renal failure, hypertensive emergency, HELLP syndrome, placental abruption or delivery before 34 weeks. Secondary outcomes included development of severe features, indication for preterm labor less than 37 weeks, incidence of severe range blood pressures, and neonatal outcomes. Student t, chi square, and Kruskal-Wallis tests where appropriate. Logistic regression used to account for potential confounders. Results Study cohort included 117 on antihypertensives and 114 not on antihypertensives. Use of antihypertensives was associated with the composite primary outcome (Odds ratio [OR], 3.88; 95% confidence interval [CI], 1.66–9.78). Use of antihypertensive medications was also associated with increased risk of prenatal diagnosis of IUGR, delivery prior to 34 weeks, development of severe features, severe blood pressure during pregnancy, earlier mean gestational age at delivery, lower mean birth weight, and higher risk of NICU admission. Logistic regression analysis showed that the association between medication requirement and our composite primary outcome persisted even after adjustment for age, BMI, and presence of gestational diabetes. Conclusion Our findings show an association between the requirement of antihypertensive medication use a significantly higher risk of composite primary outcome, prenatal diagnosis of IUGR, delivery prior to 34 weeks, and the development of severe features.

Evaluation of the Emergency Severity Index (Version 4) in Postpartum Women after Cesarean Delivery.

The Emergency Severity Index (ESI) version 4 is a 5-level triage system (1 being the highest acuity and 5 being the lowest acuity) used in the emergency department (ED). Our goal of the study was to compare rates of readmission according to ESI in postpartum women. This was a secondary analysis of a retrospective cohort study of all women who presented to the ED within 6 weeks after cesarean delivery. The acuity level was assigned by triage nurses at the time of triage presentation. Our primary outcome was postpartum readmission. To examine if the addition of blood pressure to vital sign abnormalities would improve the prediction for readmission, we created a modified ESI. We identified women who had an ESI of level 3 and reassigned to a modified ESI of level 2 if blood pressure was in the severe range. Receiver operating characteristic curves with area under the curve (AUC) were created and compared between ESI and modified ESI. Of 439 women, ESI distribution was 0.2% ESI 1, 23.7% ESI 2, 56.0% ESI 3, 19.4% ESI 4, and 0.7% ESI 5. Readmission rates by ESI level were 100% ESI 1, 47% ESI 2, 18% ESI 3, 2% ESI 4, and 0% ESI 5 (p < 0.001). Of 246 women who were assigned an ESI of 3, total 25 had severe range blood pressures and were reassigned to a modified ESI of 2. Of these 25 women, 14 were readmitted. The AUC of the modified ESI was statistically higher than that of the standard ESI (AUC: 0.77 and 95% confidence interval: 0.72-0.82 vs. AUC: 0.73 and 95% confidence interval: 0.68-0.78; p < 0.01). The ESI was a useful tool to identify women who required postpartum readmission. Incorporation of severe range blood pressure as a parameter of acuity improved the prediction of readmission. · ESI does not consider blood pressure.. · The ESI version 4 was predictive of postpartum readmission.. · Consideration of a severe range blood pressure significantly improved the prediction of readmission..

20: Ethnic differences in anti-hypertensive medication response among pregnant and postpartum patients

In the non-pregnant literature, it is suggested that Black patients respond better to calcium channel blockers than beta-blockers for the treatment of hypertension. In contrast, there are no ethnic specific recommendations in the treatment of acute, severe range pressures in pregnancy. The hypothesis of this study was that labetalol is less effective than nifedipine for treatment of acute, severe hypertension in pregnant and postpartum Black women relative to women of other ethnicities. This was a randomized, controlled trial of pregnant and postpartum women that presented with severe-range blood pressures. Patients were randomized to receive IV labetalol or oral nifedipine based on the American College of Obstetrics and Gynecology (ACOG) protocol for the management of acute hypertension in pregnancy. The primary outcome measured was the treatment duration needed to achieve the goal blood pressure of systolic pressure < 160 mmHg and diastolic pressure < 110 mmHg. The secondary outcomes of the study were the number of medication doses needed to achieve goal blood pressure and any maternal side effects. 109 women were randomized to labetalol or nifedipine from 9/2017 to 4/2019. Patient characteristics were similar between the two groups (Table 1). The median time to achieve goal blood pressure was 10 minutes for those who received IV labetalol and 20 minutes for those who received oral nifedipine (p< 0.0001) (Figure 1). There was no evidence of an effect of ethnicity on medication efficacy. In both groups, the median (IQR) number of medication dose was 1 (1-2), regardless of ethnicity. There was no significant difference in the side effect profile of the two medications. Our data suggests that labetalol and procardia are equally effective in the treatment of severe range BP in pregnancy, regardless of race. IV labetalol lowered severe blood pressures in pregnant and postpartum patients faster than nifedipine, though they were equally effective in terms of doses required to achieve goal blood pressure.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

912: Chronic Hypertension in Pregnancy: Are outcomes the same in patients who require antihypertensives?

The objective of this study is to investigate differences in maternal and fetal outcomes among pregnant patients with chronic hypertension requiring antihypertensives for adequate control versus those who do not require antihypertensives. Single-site retrospective cohort study including pregnant patients with chronic hypertension from December 2012 - December 2018. Patients were divided into two groups, those who required antihypertensives versus those who did not. The primary outcome was composite maternal morbidity which included: pregnancy loss after 20 weeks, IUGR, maternal death, maternal stroke or TIA, pulmonary edema, renal failure, hypertensive emergency, HELLP syndrome, placental abruption or delivery before 34 weeks. Secondary outcomes included neonatal outcomes and the occurrence of severe range blood pressures during pregnancy. Student t, chi square, and Kruskal-Wallis tests were used where appropriate. Adjusted odds ratios were calculated using logistic regression to account for potential confounders. Our study cohort included 117 patients in the antihypertensive group and 114 in the no antihypertensive group. Requiring antihypertensives for blood pressure control was associated with the composite primary outcome (Odds ratio [OR], 3.88; 95% confidence interval [CI], 1.66- 9.78). All individual outcomes included in the composite outcome were more common in the antihypertensive group including IUGR (OR 2.85, 95% CI: 1.01-9.21) and delivery less than 34 weeks (OR 7.17 95% CI: 2.01-38.7). Logistic regression analysis found that the association persisted even after adjustment for age, BMI, and presence of gestational diabetes. Current recommendations for treating hypertension in pregnancy with medications divide hypertensive patients into two unique groups. In our study, those who require antihypertensives during pregnancy more often experienced adverse outcomes than patients who did not. Future studies should focus on whether treatment/surveillance of patients on antihypertensives should differ from those who are not on antihypertensives.

Severe Range Blood Pressures and the Association With Hypertension Up to 2 Years Post-Delivery [31P

INTRODUCTION: While hypertension can normalize soon after delivery, some women experience prolonged periods of hypertension. We sought to determine whether severe range blood pressures on labor and delivery are associated with having hypertension 12 weeks to 2 years after delivery. METHODS: Retrospective cohort study of pregnancies with a delivery from 7/2009-7/2016. Inclusion criteria were delivery at our tertiary hospital, presence of hypertensive disorder, and a documented blood pressure 12 weeks-2 years postpartum. Blood pressures were documented for every visit between 12 weeks and 2 years postpartum. A logistic regression model was used to determine the odds of hypertension in the 2 years following delivery. Multivariable logistic regression analysis was used to adjust for confounding factors. RESULTS: 524 women met inclusion and exclusion criteria. Of these, 127 (24%) women had at least one severe range blood pressure during their hospitalization for delivery. Women with severe blood pressures were more likely to have a history of or current gestational hypertension, but less likely to have IUGR (p<0.05). Other variables were similar. However, women with severe range blood pressures during delivery hospitalization did not show a greater rate of hypertension from 12 weeks - 2 years in either unadjusted (OR 1.24 [0.83-1.85], p=0.30) or adjusted analysis (OR 1.24 [0.80-1.9], p=0.34). CONCLUSION: While 24% of women in our cohort had severe range hypertension, this was not associated with hypertension up to 2 years post-delivery. It is important to encourage all women with hypertensive disorders to follow up closely, as this alone does not seem to identify those at highest risk.

Improving Compliance With Preeclampsia Guidelines Through an Electronic Health Record Alert [19L

INTRODUCTION: Hypertensive disorders of pregnancy occur in 12-22% of all pregnancies and account for 17% of maternal mortality in the US. National guidelines for management of hypertensive disorders were developed by the American College of Obstetrics and Gynecology (ACOG) and the California Maternal Quality Care Collaborative (CMQCC). An electronic health record automated alert offers an opportunity to improve compliance with these guidelines. METHODS: A Blood Pressure Alert (BPA) was incorporated into an existing electronic health record to notify providers when a patient had a documented severe range blood pressure, defined as systolic blood pressure ≥-160 or diastolic blood pressure ≥110. Pre- and post-intervention data was collected via retrospective chart review. Compliance with national guidelines for administration of rapid-acting antihypertensive medication, IV magnesium for seizure prophylaxis, and initiation of oral antihypertensive medication postpartum was evaluated. RESULTS: Appropriate treatment of sustained severe-range blood pressure episodes with a rapid-acting antihypertensive medication within 1 hour of diagnosis improved after the implementation of the BPA (35% vs 54%, p<0.01), which was statistically significant. There was no significant change in the administration of IV magnesium sulfate (89% vs 80%, p=0.06) or prescription of oral antihypertensive medications at discharge (89% vs 93%, p=0.31). CONCLUSION: An automated electronic health record alert improved timely administration of rapid-acting anti-hypertensive medications for severe range blood pressures on an academic Labor and Delivery Unit and has the potential to improve overall compliance with ACOG and CMQCC preeclampsia guidelines. Increased adherence to these guidelines may improve maternal morbidity and mortality rates in the US.

The Effect of Chronic Hypertension on Control of Severe Range Blood Pressures in Preeclampsia [36P

INTRODUCTION: We aim to assess the impact of maternal hypertension category on the control and response of urgent hypertension. METHODS: This is a retrospective cohort study of patients who required immediate-acting antihypertensive medications outlined by the ACOG Committee Opinion #692 during the peripartum admission between June 2015 to June 2017. The patients were either diagnosed with preeclampsia with severe features (“preSF”) or chronic hypertension with superimposed preeclampsia with severe features (“cHTN+preSF”). We abstracted maternal medical history and medication dosing. Statistical significance was calculated with the Student's t-test or Mann-Whitney test. Multivariable regression analysis was used to adjust for the effect of confounders. RESULTS: We identified 326 patients, 211 with preSF and 115 with cHTN+preSF. In the antepartum period, patients with cHTN+preSF received significantly more doses of immediate-acting antihypertensive medications than those with preSF (3 vs 2 doses, p<0.01). The cHTN+preSF group also required more time for blood pressures to exit severe range (55 vs 30 minutes, p<0.01) and more frequent re-dosing of anti-hypertensive medication (2 vs 1 times, p=0.02). The differences remained significant in the multivariable regression model when controlled for age, gravidity and BMI. During the postpartum period, the same parameters were similar between the groups. CONCLUSION: While chronic hypertension is recognized as a risk factor for the development of preeclampsia, we demonstrate that it also complicates and prolongs the course of blood pressure management particularly in the antepartum period. Consideration should be given to maternal history when tailoring treatment of severe hypertension in patients with pre-eclampsia.

90: A randomized controlled trial of ibuprofen on postpartum blood pressure in hypertensive disorders of pregnancy

Nonsteroidal antiinflammatory drugs, such as ibuprofen, are common and effective analgesics in the postpartum period, but there is concern over the potential for these medications to increase blood pressure in women with hypertensive disorders of pregnancy. Our aim was to evaluate the effect of ibuprofen on blood pressure in this hypertensive population during the immediate postpartum period. In this double-blind randomized control trial, women with new diagnoses of hypertensive disorders of pregnancy without severe-range blood pressures were randomly assigned to receive a mild analgesic regimen consisting of either ibuprofen or acetaminophen, with additional medications administered as needed to achieve pain control. The primary outcome was average mean arterial pressure during postpartum hospital admission. Secondary outcomes included average mean arterial blood pressure by postpartum day, pain control, length of hospital stay, achievement of postpartum diuresis, and patient satisfaction. Sixty-one women with hypertensive disorders were randomized and completed the trial. There was no difference in average mean arterial pressure during the postpartum hospital admission (92.7 for those in the ibuprofen group versus 92.8 in the control group without nonsteroidal medication exposure, p=0.93, Table), nor was there a difference in trend of mean arterial pressure by postpartum day (p=0.25). We found no differences between groups in the secondary outcomes for pain control or length of hospital stay. There was no difference between groups for proportion of patients who met criteria for postpartum diuresis (61.3% in ibuprofen group versus 76.7% in the control group, p=0.20; Cox regression HR 0.72 [95% CI 0.39-1.32, p=0.29], Figure). A high level of satisfaction was reported, with 89.7% in the ibuprofen group and 73.3% in the control group reporting pain was "always" well controlled during hospital stay (p=0.21). In women with mild hypertensive disorders of pregnancy, no increase in postpartum blood pressure was noted in those who received ibuprofen versus those who were not exposed to nonsteroidal antiinflammatory medications for postpartum analgesia.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Management of Severe Range Blood Pressures During Obstetrical Care: A Quality Improvement Project [3L

INTRODUCTION: Hypertensive disorders of pregnancy are a leading cause of maternal and neonatal morbidity and mortality. Timeliness of treatment improves maternal and neonatal outcomes. This study assesses the impact of implementing a program for severe range blood pressure (SRBP) management during inpatient obstetrical care. METHODS: We prospectively collected data from a single academic center during 2015-2016 comparing outcomes before and after a system change. The changes included 1) an algorithm to improve blood pressure (BP) recheck times (for validating SRBP) and time to intravenous medication when indicated; 2) improved medication access making all medications equally available; and 3) multidisciplinary training including simulation sessions. All patients with ICD-10 codes of pregnancy-related hypertensive disorders who had SRBP were evaluated over a three-month period before and after program implementation. SRBP treatment included intravenous labetalol or hydralazine or oral nifedipine. Primary endpoints compared time to BP recheck, time to medication when indicated and type of medication. RESULTS: More women had a BP recheck within one hour post-implementation (330/344, 95.9%) vs. pre-implementation (390/425, 91.7%) (P=.0025). A similar improvement occurred when evaluating BP recheck within 10 minutes (60.5% vs. 40.0%, respectively, P=.0001). For the 113 post-implementation and 89 pre-implementation SRBP events requiring treatment, time to medication did not improve (median 13 and 14 minutes, respectively, P=.40). Use of labetalol vs. hydralazine post-implementation increased from 13.3% to 38.1% (P=.0001); nifedipine was rarely used (1 and 3 patients, respectively). CONCLUSION: Implementation of an algorithm to treat SRBP can improve BP recheck rates and impact choice of intravenous medications.

Butorphanol use in laboring patients with preeclampsia or chronic hypertension.

The American College of Obstetricians and Gynecologists (ACOG) recommends against the use of butorphanol in patients diagnosed with preeclampsia or chronic hypertension secondary to a theoretical concern that the drug will further elevate blood pressures. No past study has examined the drug's potential to elevate blood pressures in laboring patients. In this retrospective cohort study all chronic hypertensive and preeclamptic patients who underwent an induction of labor and delivered a viable, singleton pregnancy between the dates of 1/1/2013 and 12/31/2014 at a single academic hospital were included. The use of butorphanol in chronically hypertensive patients during labor was not associated with the presence of severe range blood pressures during labor (OR=0.92 95% CI: (0.04-19.34) P=0.96). In preeclamptic patients there was similarly no change in the frequency of severe range blood pressures with the use of the drug (OR=0.59 95% CI: (0.19-1.83) P=0.36). In laboring patients with chronic hypertension or preeclampsia butorphanol is not associated with severe range blood pressures, and therefore it is a reasonable option for providing pain relief in these populations.

Mirror Syndrome: A Reflection of Fetal Health

Background Mirror syndrome was first described as a clinical occurrence in 1892 by John Ballantyne in which nonimmune hydrops fetalis complicates the pregnancy. Maternal edema and other complications including preeclampsia mirror the hydrops noted in the fetus. The purpose of this case presentation is to familiarize the perinatal nurse with this rare complication of pregnancy and to describe the ethical dilemma of immediate delivery versus postponing delivery due to extreme prematurity. Case Three weeks after the diagnosis of nonimmune hydrops fetalis secondary to a large sacrococcygeal tumor, the woman at 24 weeks 5 days gestation presented with severe bilateral lower extremity edema. On admission the woman was noted to have severe range blood pressures, proteinuria, and epigastric pain. Laboratory data also revealed elevated liver enzymes, severe anemia with hemoglobin of 5.0 and hematocrit of 15.3, and thrombocytopenia. Ultrasound and magnetic resonance imaging (MRI) studies revealed worsening nonimmune hydrops fetalis and a significant increase in the size of the sacrococcygeal tumor rivaling the size of the fetus. The woman was immediately started on mjagnesium sulfate, labetalol, betamethasone, and blood replacement products. Several consults were performed with neonatology, pediatric surgery, hematology, and maternal/fetal medicine. The maternal/fetal medicine team assumed care of the woman and encouraged immediate delivery. The woman and her family wanted to continue the pregnancy until 28 weeks to allow for additional maturity of the fetus. Discussions ensued outlining the risks for the mother and to the fetus of continuing the pregnancy. Conclusion At this point the mother continued to refuse delivery. An ethicist was called in to assist and described the four fundamental principles of ethics, beneficence, autonomy, nonmaleficence, and justice, and their relationship to this case. After 2 days of hospitalization the woman relented and a cesarean was performed. The mother needed additional blood products but was discharged to home after 6 days. The newborn underwent emergency surgery to remove the tumor, however, she succumbed to heart failure during the postoperative period. Mirror syndrome was first described as a clinical occurrence in 1892 by John Ballantyne in which nonimmune hydrops fetalis complicates the pregnancy. Maternal edema and other complications including preeclampsia mirror the hydrops noted in the fetus. The purpose of this case presentation is to familiarize the perinatal nurse with this rare complication of pregnancy and to describe the ethical dilemma of immediate delivery versus postponing delivery due to extreme prematurity. Three weeks after the diagnosis of nonimmune hydrops fetalis secondary to a large sacrococcygeal tumor, the woman at 24 weeks 5 days gestation presented with severe bilateral lower extremity edema. On admission the woman was noted to have severe range blood pressures, proteinuria, and epigastric pain. Laboratory data also revealed elevated liver enzymes, severe anemia with hemoglobin of 5.0 and hematocrit of 15.3, and thrombocytopenia. Ultrasound and magnetic resonance imaging (MRI) studies revealed worsening nonimmune hydrops fetalis and a significant increase in the size of the sacrococcygeal tumor rivaling the size of the fetus. The woman was immediately started on mjagnesium sulfate, labetalol, betamethasone, and blood replacement products. Several consults were performed with neonatology, pediatric surgery, hematology, and maternal/fetal medicine. The maternal/fetal medicine team assumed care of the woman and encouraged immediate delivery. The woman and her family wanted to continue the pregnancy until 28 weeks to allow for additional maturity of the fetus. Discussions ensued outlining the risks for the mother and to the fetus of continuing the pregnancy. At this point the mother continued to refuse delivery. An ethicist was called in to assist and described the four fundamental principles of ethics, beneficence, autonomy, nonmaleficence, and justice, and their relationship to this case. After 2 days of hospitalization the woman relented and a cesarean was performed. The mother needed additional blood products but was discharged to home after 6 days. The newborn underwent emergency surgery to remove the tumor, however, she succumbed to heart failure during the postoperative period.