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ACOG recommends acute-onset, severe hypertension be treated with first line-therapy (IV labetalol, IV hydralazine or PO nifedipine) within 60 minutes to reduce risk of maternal morbidity and mortality. Our objective was to identify barriers that lead to delayed treatment.
We identified 419 patients with discharge diagnoses of chronic HTN, gestational HTN or preeclampsia using ICD-10 codes and pharmacy database at an academic institution during the year 2017. 188 subjects (44.8%) experienced HTN emergency (systolic BP>160 or diastolic BP>110, confirmed 15 min apart). 41 were excluded for incomplete records, leaving 147 for analysis. A retrospective cohort study was performed comparing women with delay in first line therapy vs those treated under 60 min. We evaluated maternal characteristics, presenting symptoms and circumstances, timing of HTN emergency, gestational age at presentation, trend of maternal BP between first two severe readings, and administered medications. Parametric and nonparametric statistics were used with p<0.05 as statistically significant.
Of the 147 women, 79 (53.7%) had delayed treatment vs. 68 (46.3%) treated within 60 min. Presentation with initial BP in the non-severe range resulted in 3X the odds of having delayed treatment vs presenting with initial severe BP reading (OR=3.09, 95% CI:1.57-6.07). Absence of symptoms of preeclampsia resulted in 2.1X the odds of delayed treatment (OR=2.08, 95%CI:1.02-4.22). HTN emergencies between 10pm-6am were ∼2.5X more likely to have delayed treatment vs those between 6am-10pm (OR 2.57, 95% CI: 1.00-6.60). Patients treated under 60 min had a lower gestational age at presentation 35.4±4wk vs those with delayed treatment 36.9±3.6wks, p<0.008. For every 1wk increase in GA at presentation, there was a 9% increase in the likelihood of delayed treatment (OR 0.91; 95%CI:0.83-0.99). A decrease in mean BP between first two consecutive severe BP readings showed a trend towards ∼2X the odds of delayed treatment vs a rise in mean BP (OR=1.92, 95% CI: 0.98-3.79). No other differences were found between the groups.
Initial BP in non-severe range, absence of preeclampsia symptoms, presentation overnight, increasing gestational age at presentation, and decrease in mean BP in the two consecutive severe BP readings are barriers that lead to delay in treatment of obstetric hypertensive emergency.