Advertisement

Early standardized treatment of critical blood pressure elevations is associated with a reduction in eclampsia and severe maternal morbidity

Published:January 30, 2017DOI:https://doi.org/10.1016/j.ajog.2017.01.008

      Background

      Hypertensive disorders of pregnancy result in significant maternal morbidity and mortality. State and national guidelines have been proposed to increase treatment of patients with hypertensive emergencies or critically elevated blood pressures. There are limited data available to assess the impact of these recommendations on maternal morbidity.

      Objective

      The purpose of this prospective quality improvement project was to determine if maternal morbidity would be improved using a standardized approach for treatment of critically elevated blood pressures.

      Study Design

      In all, 23 hospitals participated in this project. Treatment recommendations included the use of an intravenous blood pressure medication and magnesium sulfate when there was a sustained blood pressure of ≥160 mm Hg systolic and/or ≥110 mm Hg diastolic. Compliance with the metric recommendations was monitored based on the number of patients treated with an intravenous blood pressure medication, use of magnesium sulfate, and if they received a timely postpartum follow-up appointment. The metric was scored as all or none; missing any of the 3 metric components was considered noncompliant. From January through June 2015 baseline data were collected and hospitals were made aware that ongoing monitoring of compliance would begin in July 2015 through June 2016. The primary outcomes were composite metric compliance, the incidence of eclampsia per 1000 births, and severe maternal morbidity.

      Results

      During the 18 months of this study there were 69,449 births. Within this population, 2034 met criteria for a critically elevated blood pressure, preeclampsia, or superimposed preeclampsia with severe features. Of this group, 1520 had a sustained critical blood elevation. Initial compliance with treatment recommendations was low (50.5%) and increased to >90% after April 2016 (P < .001). Compliance with utilization of intravenous blood pressure medication increased by 33.2%, from a baseline of 57.1-90.3% (P < .01) during the last 6 months of monitoring. Compliance with utilization of magnesium sulfate increased by 10.8%, from a baseline of 85.4-96.2% (P < .01). The incidence of eclampsia declined by 42.6% (1.15 ± 0.15/1000 to 0.62 ± 0.09/1000 births). Severe maternal morbidity decreased by 16.7% from 2.4 ± 0.10% to 2.0 ± 0.15% (P < .01).

      Conclusion

      We noted 3 important findings: (1) compliance with state and national treatment guidelines is low without monitoring; (2) high levels of compliance can be achieved in a relatively short period of time; and (3) early intervention with intravenous blood pressure medication and magnesium sulfate for verified sustained critical maternal blood pressures resulted in a significant reduction in the rate of eclampsia and severe maternal morbidity. The reduction in the rate of eclampsia could only partially be attributed to the increase in the use of magnesium sulfate, suggesting an additive or synergistic effect of the combined treatment of an antihypertensive medication and magnesium sulfate on the rate of eclampsia and severe maternal morbidity.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Duley L.
        The global impact of pre-eclampsia and eclampsia.
        Semin Perinatol. 2009; 33: 130-137
        • Magee L.A.
        • von Dadelszen P.
        • Singer J.
        • et al.
        The CHIPS randomized controlled trial (control of hypertension in pregnancy study): is severe hypertension just an elevated blood pressure?.
        Hypertension. 2016; 68: 1153-1159
        • Creanga A.A.
        • Berg C.J.
        • Ko J.Y.
        • et al.
        Maternal mortality and morbidity in the United States: where are we now?.
        J Womens Health (Larchmt). 2014; 23: 3-9
        • American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy
        Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy.
        Obstet Gynecol. 2013; 122: 1122-1131
      1. Council on Patient Safety in Women's Health Care. Severe hypertension in pregnancy. Available at: http://safehealthcareforeverywoman.org/patient-safety-bundles/severe-hypertension-in-pregnancy. Accessed Nov. 1, 2015.

      2. Druzin ML, Shields LE, Peterson NL, Cape V. Preeclampsia toolkit: improving health care response to preeclampsia. California Maternal Quality Care Collaborative toolkit to Transform Maternity Care. Developed under contract #11-10006 with the California Department of Public Health; Maternal Child and Adolescent Health Division; published by the California Maternal Quality Care Collaborative, November 2013.

      3. New York State Department of Health. Hypertensive disorders in pregnancy. Available at: https://www.health.ny.gov/professionals/protocols_and_guidelines/hypertensive_disorders/2013_hdp_executive_summary.pdf. Accessed May 30, 2013.

      4. Florida Perinatal Collaborative. Hypertension in pregnancy HIP toolbox, 2016 (v2 2016). Available at: health.usf.edu/publichealth/chiles/fpqc/hip_toolbox. Accessed Dec. 24. 2016.

        • Shields L.E.
        • Kilpatrick S.J.
        • Melsop K.
        • Peterson N.
        Timely assessment and treatment of preeclampsia reduces maternal morbidity.
        Am J Obstet Gynecol. 2015; 212: S69
        • Shields L.E.
        • Wiesner S.
        • Klein C.
        • Pelletreau B.
        • Hedriana H.L.
        Use of maternal early warning trigger tool reduces maternal morbidity.
        Am J Obstet Gynecol. 2016; 214: 527.e1-527.e6
        • Callaghan W.M.
        • Mackay A.P.
        • Berg C.J.
        Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991-2003.
        Am J Obstet Gynecol. 2008; 199: 133.e1-133.e8
        • Goldenberg R.L.
        • Jones B.
        • Griffin J.B.
        • et al.
        Reducing maternal mortality from preeclampsia and eclampsia in low-resource countries–what should work?.
        Acta Obstet Gynecol Scand. 2015; 94: 148-155
        • MacKay A.P.
        • Berg C.J.
        • Atrash H.K.
        Pregnancy-related mortality from preeclampsia and eclampsia.
        Obstet Gynecol. 2001; 97: 533-538
      5. California Maternal Quality Care Collaborative. The California pregnancy-associated mortality review, report from 2002-2003 Maternal Death Reviews. 2011. Available at: https://www.cdph.ca.gov/data/statistics/Documents/MOCA-PAMR-MaternalDeathReview-2002-03.pdf. Accessed September 30, 2016.

        • Martin Jr., J.N.
        • Thigpen B.D.
        • Moore R.C.
        • Rose C.H.
        • Cushman J.
        • May W.
        Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure.
        Obstet Gynecol. 2005; 105: 246-254
        • Kilpatrick S.J.
        • Abreo A.
        • Greene N.
        • et al.
        Severe maternal morbidity in a large cohort of women with acute severe intrapartum hypertension.
        Am J Obstet Gynecol. 2016; 215: 91.e1-91.e7
        • Altman D.
        • Carroli G.
        • Duley L.
        • et al.
        Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomized placebo-controlled trial.
        Lancet. 2002; 359: 1877-1890
        • ACOG Committee on Obstetric Practice
        Emergent therapy for acute-onset, severe hypertension with preeclampsia or eclampsia. Committee opinion no. 514.
        Obstet Gynecol. 2011; 118: 1465-1468
        • Bailit J.L.
        • Grobman W.A.
        • McGee P.
        • et al.
        Does the presence of a condition-specific obstetric protocol lead to detectable improvements in pregnancy outcomes?.
        Am J Obstet Gynecol. 2015; 213: 86.e1-86.e6