Speeding up treatment for pregnancy-related hypertension

Under the new treatment protocol, detailed in The Joint Commission Journal on Quality and Patient Safety, nearly 95% of patients were treated within 30 minutes of confirmed severe hypertension. Speeding up treatment reduces the risk of maternal stroke and other morbidity, compared to the current national standard of treating pregnant hypertension patients within 30 to 60 minutes of confirmed diagnosis.

Investigators also found that while Black, Asian and Hispanic women were more likely than white women to experience severe pregnancy-related hypertension, race and ethnicity did not play a role in the timeliness of treatment.

"We are constantly looking to develop strategies to decrease both severe maternal morbidity and mortality, while identifying ways of narrowing the racial disparity gap," said John Ozimek, DO, the director of Labor & Delivery and the Maternal-Fetal Care Unit at Cedars-Sinai and first author of the study. "One of the ways that we can minimize, or at least decrease risk of complication from severe hypertension, is by recognizing and treating it quickly."

Hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and chronic hypertension with superimposed preeclampsia. In the U.S., all remain a significant cause of severe maternal morbidity that accounts for approximately 7% of pregnancy-related deaths. And for Black women, pregnancy-related death ratios are more than three times higher than those of white women.

To help overcome some of these issues, the team at Cedars-Sinai looked to improve the timely treatment of severe hypertension that can specifically target and address interventions to possibly improve these outcomes.

Working with residents, physicians and nurses, the team created a standardized protocol for the diagnosis and treatment of severe pregnancy-related hypertension to help eliminate any barriers.

They then created an automated monthly report that identified women who experienced severe hypertension during their labor and delivery admission. The record for each case was reviewed to determine if treatment was within 30 minutes. These rates were also compared by race and ethnicity.

From April 1, 2019, through March 31, 2021, there were 12,069 deliveries at Cedars-Sinai. A total of 684 women had at least one episode of severe hypertension. Of those women, 441 met criteria for and received treatment, with 417 (94.6%) treated in a timely manner.

For those not treated within the 30 minutes, common causes included patient refusal of medication, slight delay in notifying the healthcare provider, or antihypertensive medications temporarily withheld during assessment and treatment of concurrent morbidity. In most cases, delay was minimal and still met the national criteria for treatment.

Investigators also found that Black, Asian and Hispanic women were all more likely than white women to experience severe hypertension requiring treatment. However, race and ethnicity in this specific parameter did not play a contributing factor in terms of delays in treatment.

"The fact that Black women were more likely to experience hypertension than white women was not unexpected, and we know that is due to a variety of complex factors," said Ozimek, who is also an assistant professor of Obstetrics and Gynecology. "But what we saw was timeliness of treatment for severe hypertension didn't differ between the groups, which is so important."

Said Sarah Kilpatrick, MD, PhD, chair of the Department of Obstetrics and Gynecology at Cedars-Sinai and senior author of the paper, "The really big point we want to drive home is that we now have this automated program that other institutions can duplicate to be able to audit their own timeliness of treatment of women with severe hypertension and identify ways to improve severe maternal morbidity and mortality within their own systems."