Background
Obstetric hypertensive emergency is defined as having systolic blood pressure ≥160
mm Hg or diastolic blood pressure ≥110 mm Hg, confirmed 15 minutes apart. The American
College of Obstetricians and Gynecologists recommends that acute-onset, severe hypertension
be treated with first line-therapy (intravenous labetalol, intravenous hydralazine
or oral nifedipine) within 60 minutes to reduce risk of maternal morbidity and death.
Objective
Our objective was to identify barriers that lead to delayed treatment of obstetric
hypertensive emergency.
Study Design
A retrospective cohort study was performed that compared women who were treated appropriately
within 60 minutes vs those with delay in first-line therapy. We identified 604 patients
with discharge diagnoses of chronic hypertension, gestational hypertension, or preeclampsia
using International Classification of Diseases–10 codes and obstetric antihypertensive
usage in a pharmacy database at 1 academic institution from January 2017 through June
2018. Of these, 267 women (44.2%) experienced obstetric hypertensive emergency in
the intrapartum period or within 2 days of delivery; the results from 213 women were
used for analysis. We evaluated maternal characteristics, presenting symptoms and
circumstances, timing of hypertensive emergency, gestational age at presentation,
and administered medications. Chi square, Fisher’s exact, Wilcoxon rank-sum, and sample
t-tests were used to compare the 2 groups. Univariable logistic regression was applied
to determine predictors of delayed treatment. Multivariable regression model was also
performed; C-statistic and Hosmer and Lemeshow goodness-of-fit test were used to assess
the model fit. A result was considered statistically significant at P<.05.
Results
Of the 213 women, 110 (51.6%) had delayed treatment vs 103 (48.4%) who were treated
within 60 minutes. Patients who had delayed treatment were 3.2 times more likely to
have an initial blood pressure in the nonsevere range vs those who had timely treatment
(odds ratio, 3.24; 95% confidence interval, 1.85–5.68). Timeliness of treatment was
associated with presence or absence of preeclampsia symptoms; patients without preeclampsia
symptoms were 2.7 times more likely to have delayed treatment (odds ratio, 2.68; 95%
confidence interval, 1.50–4.80). Patients with hypertensive emergencies that occurred
overnight between 10 pm and 6 am were 2.7 times more likely to have delayed treatment vs those emergencies that occurred
between 6 am and 10 pm (odds ratio, 2.72; 95% confidence interval, 1.27–5.83). Delayed treatment also had
an association with race, with white patients being 1.8 times more likely to have
delayed treatment (odds ratio, 1.79; 95% confidence interval, 1.04–3.08). Patients
who were treated at <60 minutes had a lower gestational age at presentation vs those
with delayed treatment (34.6±5 vs 36.6±4 weeks, respectively; P<.001). For every 1-week increase in gestational age at presentation, there was a
9% increase in the likelihood of delayed treatment (odds ratio, 1.11; 95% confidence
interval, 1.04–1.19). Another factor that was associated with delay of treatment was
having a complaint of labor symptoms, which made patients 2.2 times as likely to experience
treatment delay (odds ratio, 2.17; 95% confidence interval, 1.07–4.41).
Conclusion
Initial blood pressure in the nonsevere range, absence of preeclampsia symptoms, presentation
overnight, white race, having complaint of labor symptoms, and increasing gestational
age at presentation are barriers that lead to a delay in the treatment of obstetric
hypertensive emergency. Quality improvement initiatives that target these barriers
should be instituted to improve timely treatment.
Key words
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Article Info
Publication History
Published online: February 14, 2020
Accepted:
February 3,
2020
Received in revised form:
January 30,
2020
Received:
October 26,
2019
Footnotes
The authors report no conflict of interest. There are no funding sources to report.
Cite this article as: Kantorowska A, Heiselman CJ, Halpern TA, et al. Identification of factors associated with delayed treatment of obstetric hypertensive emergencies. Am J Obstet Gynecol 2020;223:250.e1-11.
Identification
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