Advertisement

Timely treatment of severe hypertension and risk of severe maternal morbidity at an urban hospital

  • Danielle M. VUNCANNON
    Correspondence
    Corresponding Author. Danielle Vuncannon, MD, Department of Gynecology and Obstetrics, Emory University School of Medicine, Emory Perinatal Center, 550 Peachtree Street, NE, Medical Office Tower 15th Floor, Atlanta, GA, 30308, 252-531-0011
    Affiliations
    Atlanta, Georgia; Department of Gynecology and Obstetrics, Emory University School of Medicine, 80 Jesse Hill Jr. Drive SE, Atlanta, GA, 30303
    Search for articles by this author
  • Marissa H. PLATNER
    Affiliations
    Atlanta, Georgia; Department of Gynecology and Obstetrics, Emory University School of Medicine, 80 Jesse Hill Jr. Drive SE, Atlanta, GA, 30303
    Search for articles by this author
  • Sheree L. BOULET
    Affiliations
    Atlanta, Georgia; Department of Gynecology and Obstetrics, Emory University School of Medicine, 80 Jesse Hill Jr. Drive SE, Atlanta, GA, 30303
    Search for articles by this author
Published:November 12, 2022DOI:https://doi.org/10.1016/j.ajogmf.2022.100809

      Abstract

      Background

      : Hypertensive disorders of pregnancy have been identified as a leading contributor to severe maternal morbidity and maternal mortality. Pregnant persons with hypertensive disorders who develop severe hypertension at delivery admission have been shown to experience higher rates of severe maternal morbidity relative to those without severe hypertension. Current guidelines recommend prompt treatment of severe hypertension given known associated maternal and fetal risks; however, only one prior study has described an association between timeliness of antihypertensive therapy and risk of severe maternal morbidity.

      Objective

      : We sought to characterize how development of severe hypertension impacts risk of severe maternal morbidity and how timely treatment of severe intrapartum hypertension may affect this risk.

      Study Design

      : We conducted a population cohort study of deliveries with and without hypertensive disorders of pregnancy at a single urban hospital between 2016 and 2018. Among deliveries of persons with hypertensive disorders of pregnancy, we identified those with persistent severe hypertension (defined as blood pressure ≥160/105 mmHg sustained over ≥15 minutes) and further classified individuals with severe hypertension as having received timely (within 60 minutes) or delayed treatment. Severe maternal morbidity was identified using a composite measure developed by the Centers for Disease Control and Prevention. We calculated overall and indicator-specific rates of severe maternal morbidity for four categories of deliveries: without hypertensive disorder of pregnancy, hypertensive disorder of pregnancy without severe hypertension, severe hypertension with timely treatment, and severe hypertension with delayed treatment. We assessed the association between hypertensive disorder of pregnancy, severe hypertension, timeliness of treatment, and severe maternal morbidity using multivariable robust Poisson regression, adjusting for demographic and clinical characteristics.

      Results

      : Of 3,723 delivery hospitalizations within the study timeframe, 32.3% (1,204/3,723) were complicated by presence of a hypertensive disorder without severe hypertension and 5.7% (211/3,723) by presence of a hypertensive disorder with severe hypertension. Among those with severe hypertension, 48.8% (103/211) received timely treatment. Compared with deliveries not complicated by a hypertensive disorder, severe maternal morbidity risk was increased for hypertensive disorder of pregnancy without severe hypertension (124.4 per 1,000 vs. 52.0 per 1,000; adjusted risk ratio (aRR) 1.84, 95% confidence interval (CI) 1.41-2.40), severe hypertension with timely treatment (233.0 per 1,000; aRR 3.81, 95% CI 2.45-5.92), and severe hypertension with delayed treatment (305.6 per 1,000; aRR 5.38, 95% CI 3.75-7.73).

      Conclusion

      : Patients with hypertensive disorders of pregnancy are at an elevated risk of severe maternal morbidity, and development of severe hypertension further increases this risk. Timely antihypertensive treatment is associated with lower risk of severe maternal morbidity among those with severe hypertension. These findings emphasize the importance of provider education and quality improvement efforts aimed at expediting treatment of severe hypertension.

      Keywords

      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 MFM
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Centers for Disease Control and Prevention
        Pregnancy Mortality Surveillance System. 2021; (Accessed March 20)
        • Callaghan WM.
        Overview of maternal mortality in the United States.
        Semin Perinatol. 2012; 36: 2-6
        • Bailey ZD
        • Krieger N
        • Agenor M
        • et al.
        Structural racism and health inequities in the USA: evidence and interventions.
        Lancet. 2017; 389: 1453-1463
        • Howell EA.
        Reducing disparities in severe maternal morbidity and mortality.
        Clin Obstet Gynecol. 2018; 61: 387-399
        • Hall WJ
        • Chapman MV
        • Lee KM
        • et al.
        Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review.
        Am J Public Health. 2015; 105: e60-e76
        • Centers for Disease Control and Prevention
        Severe Maternal Morbidity. 2021; (Accessed March 20)
        • American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine
        Severe maternal morbidity: screening and review.
        Am J Obstet Gynecol. 2016; 215: B17-B22
        • Zhang J
        • Meikle S
        • Trumble A.
        Severe maternal morbidity associated with hypertensive disorders in pregnancy in the United States.
        Hypertens Pregnancy. 2003; 22: 203-212
        • Samadi AR
        • Mayberry RM
        • Zaidi AA
        • et al.
        Maternal hypertension and associated pregnancy complications among African-American and other women in the United States.
        Am J Obstet Gynecol. 1996; 87: 557-563
      1. Finger KR, Mabry-Hernandez I, Ngo-Metzger Q, et al. Delivery hospitalizations involving preeclampsia and eclampsia, 2005-2014: statistical brief #222. In: Health Care Cost and Utilization Project (HCUP) Statistical Briefs. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb222-Preeclampsia-Eclampsia-Delivery-Trends.pdf. Accessed March 29, 2021.

        • Wallis AB
        • Saftlas AF
        • Hsia J
        • et al.
        Secular trends in the rates of preeclampsia, eclampsia, and gestational hypertension, United States, 1987-2004.
        Am J Hypertens. 2008; 21: 521-526
        • 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.
        Am J Obstet Gynecol. 2013; 122: 1122-1131
        • American College of Obstetricians and Gynecologists
        Committee Opinion no. 692: emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period.
        Am J Obstet Gynecol. 2017; 129: e90-e95
        • Kilpatrick SJ
        • Abreo A
        • Green N
        • et al.
        Severe maternal morbidity in a large cohort of women with acute severe intrapartum hypertension.
        Am J Obstet Gynecol. 2016; 215 (92.e1-7)
        • Gupta M
        • Greene N
        • Kilpatrick SJ.
        Timely treatment of severe maternal hypertension and reduction in severe maternal morbidity.
        Hypertens Pregnancy. 2018; 14: 55-58
        • American College of Obstetricians and Gynecologists
        Practice bulletin no. 203: chronic hypertension in pregnancy.
        Am J Obstet Gynecol. 2019; 133: e26-e50
        • American College of Obstetricians and Gynecologists
        Practice bulletin no. 202: gestational hypertension and preeclampsia.
        Am J Obstet Gynecol. 2019; 133: e1-e25
      2. Centers for Disease Control and Prevention. How does CDC identify severe maternal morbidity? https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm. Accessed March 20, 2021.

        • Naimi AI
        • Whitcomb BW.
        Estimating risk ratios and risk differences using regression.
        Am J Epidemiol. 2020; 189: 508-510
        • Kotelchuck M.
        The adequacy of prenatal care utilization index: its US distribution and associated with low birthweight.
        Am J Public Health. 1994; 84: 1486-1489
        • Boulet SL
        • Platner M
        • Joseph NT
        • et al.
        Hypertensive Disorders of Pregnancy, Cesarean Delivery, and Severe Maternal Morbidity in an Urban Safety-Net Population.
        Am J Epidemiol. 2020; 189: 1502-1511
        • Fingar KR
        • Hambrick MW
        • Heslin KC
        • et al.
        Trends and Disparities in Delivery Hospitalizations Involving Severe Maternal Morbidity, 2006-2015: statistical brief #243.
        Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality, Rockville, MD2018 (Accessed April 3, 2021)
      3. Counsel on Patient Safety in Women's Health Care. Severe Hypertension in Pregnancy Bundle. Available at: https://saferbirth.org/psbs/severe-hypertension-in-pregnancy/. Accessed October 21, 2022.

        • Martin C
        • Pappas J
        • Johns K
        • et al.
        Semiautonomous Treatment Algorithm for the Management of Severe Hypertension in Pregnancy.
        Obstet Gynecol. 2021; 137: 211-217
        • Martin C
        • Johns K
        • Yao R
        • et al.
        Impact of Nurse Driven EMR Pathway for treatment of Severe Hypertension in Pregnancy.
        Obstet Gynecol. 2020; 135
        • Combs CA
        • Allbert JR
        • Hameed AB
        • et al.
        Society for Maternal-Fetal Medicine Special Statement: A quality metric for evaluating timely treatment of severe hypertension.
        Am J Obstet Gynecol. 2022; 226: B2-B9
        • Metcalfe A
        • Sheikh M
        • Hetherington E
        Impact of the ICD-9-CM to ICD-10-CM transition on the incidence of severe maternal morbidity among delivery hospitalizations in the United States.
        Am J Obstet Gynecol. 2021; 225 (422.e1-422.e11)