Hypertension: Original Research
Improving Obstetric Hypertensive
Emergency Treatment in a Tertiary Care
Women’s Emergency Department
Rosemary J. Froehlich, MD, Lindsay Maggio, MD,
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and Brenna L. Hughes, MD
OBJECTIVE: To assess treatment outcomes associated
with an obstetric hypertensive emergency quality
improvement intervention instituted in a tertiary care
women’s emergency department.
METHODS: We conducted a cohort study of pregnant
(20 weeks of gestation or greater) and postpartum (6
weeks of gestation or less) women treated for hyperten-
sive emergency (systolic blood pressure [BP] 160 mm Hg
or greater, diastolic 110 mm Hg or greater, or both)
before and after a quality improvement intervention. A
multidisciplinary task force revised clinical guidelines
and nursing policy, updated electronic order sets, and
provided staff education and clinical management aids.
Data were collected by electronic chart review. The
primary outcome was achieving goal BP (systolic
150 mm Hg or less and diastolic 100 mm Hg or less)
within an hour of initial therapy. Secondary outcomes
From the Department of Obstetrics, Gynecology, and Reproductive Sciences,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; the Depart-
ment of Obstetrics and Gynecology, Women & Infants Hospital, Warren Alpert
Medical School of Brown University, Providence, Rhode Island; the Department
of Obstetrics and Gynecology, High Risk Pregnancy Consultants, Florida Hos-
pital Medical Group, Maitland, Florida; and the Department of Obstetrics &
Gynecology, Duke University, Durham, North Carolina.
Presented as a poster at the Society for Maternal-Fetal Medicine’s 38th Annual
Pregnancy Meeting, January 29–February 3, 2018, Dallas, TX.
Each author has indicated that he or she has met the journal’s requirements for
authorship.
Received May 1, 2018. Received in revised form June 13, 2018. Accepted June
22, 2018.
Corresponding author: Rosemary J. Froehlich, MD, Department of Obstetrics,
Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center,
300 Halket Street, Suite 2221, Pittsburgh, PA 15213; email: froehlichr@mail.
magee.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2018 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/18
850 VOL. 132, NO. 4, OCTOBER 2018
Copyright ª by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
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Phinnara Has, MS, Roxanne Vrees, MD,
included time from first severe BP to 1) first antihyper-
tensive treatment and 2) goal BP.
RESULTS: There were no significant differences in base-
line characteristics in the preintervention (n5173; Sep-
tember 2014 to September 2015) and postintervention
(n5173; December 2015 to November 2016) groups,
including gestational age, days postpartum, maternal
age, race–ethnicity, or comorbidities. We found no sig-
nificant difference in primary outcome frequency: 41%
achieved goal BP within 60 minutes preintervention vs
47% postintervention (P5.28). Median time from first
severe BP to first treatment was unchanged (30 minutes
preintervention vs 29 minutes postintervention, P5.058);
however, median time from first severe BP to goal BP
decreased significantly (122 vs 95 minutes, P5.04). Con-
firmation of hypertensive emergency within 15 minutes
(recommended) was only achieved in approximately 20%
of women in either group. More women initially received
intravenous antihypertensive treatment after the inter-
vention (52% preintervention vs 80% postintervention,
P,.001).
CONCLUSION: A quality improvement initiative was
not associated with more women achieving BP control
within an hour of obstetric hypertensive emergency
treatment, but was associated with decreased time to
achieve control. This suggests improved clinical practice
after the intervention.
(Obstet Gynecol 2018;132:850–8)
DOI: 10.1097/AOG.0000000000002809
H ypertension during pregnancy is an important
cause of maternal morbidity and mortality.1 Avoid-
ance of prolonged maternal exposure to severe hyper-
tension (systolic blood pressure [BP] 160 mm Hg or
greater or diastolic BP 110 mm Hg or greater) is para-
mount to the prevention of serious adverse outcomes
such as intracranial hemorrhage and death.2 The Amer-
ican College of Obstetricians and Gynecologists
OBSTETRICS & GYNECOLOGY
Fig. 1. Quality improvement inter-
vention timeline, 2015.
Froehlich. Obstetric Hypertensive
Emergency Treatment. Obstet Gynecol
2018.

(ACOG) recently updated national guidelines to Obstetric hypertensive emergency is frequently

improve identification and care of women with hyper-
tension in pregnancy and published three treatment al-
gorithms for hypertensive emergency.3,4 Each starts with
a first-line antihypertensive agent: intravenous (IV) labe-
talol, IV hydralazine, or oral nifedipine.3 Subspecialty
consultation is advised if BPs remain severely elevated
after approximately 1 hour of treatment, suggesting that
most patients should achieve BP control within 60 mi-
nutes of initial treatment. Blood pressure control has pre-
viously been defined in comparative antihypertensive
trials as systolic BP 150 mm Hg or less and diastolic
BP 100 mm Hg or less.5–7
treated in an emergency department or obstetric triage
unit. At Women & Infants Hospital, a tertiary care
center affiliated with Brown University, women are
treated in a specialty emergency department run by
obstetrician–gynecologists, which also houses obstet-
ric triage. We aimed to assess treatment outcomes
associated with a quality improvement intervention
designed to align clinical practice in this women’s
emergency department with updated ACOG guide-
lines and hypothesized that more women would ach-
ieve goal BP within an hour of therapy after using this
more aggressive treatment approach.

Fig. 2. Obstetric hypertensive emer-

gency treatment protocol (A), includ-
ing treatment algorithms (B). Pregnant
and postpartum hypertensive emer-
gency (20 weeks of gestation or
greater and 6 weeks postpartum or
less). Intravenous (IV) therapy is pre-
ferred initially unless IV access is un-
achievable within 15 minutes. SBP,
systolic blood pressure; DBP, diastolic
blood pressure; MFM, maternal-fetal
medicine.
Froehlich. Obstetric Hypertensive Emer-
gency Treatment. Obstet Gynecol 2018.

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Fig. 3. Flow diagram of included participants. IV, intravenous.
Froehlich. Obstetric Hypertensive Emergency Treatment. Obstet Gynecol 2018.

MATERIALS AND METHODS
After institutional review board and quality council
approval (Women & Infants Hospital [#15-0064] on
August 11, 2015), we implemented a quality improve-
ment intervention in the emergency department of
Women & Infants Hospital and conducted a cohort
study of women treated for obstetric hypertensive
emergency before and after the intervention to assess
its effects. As described previously, Women & Infants
Hospital is a tertiary care center affiliated with Brown
University. It is the largest obstetric hospital in Rhode
Island, with more than 8,000 deliveries per year and is
a referral center for patients from Rhode Island, east-
ern Connecticut, and southeastern Massachusetts. The
emergency department, which also houses obstetric
triage, is run by obstetrician–gynecologists and

Table 1. Baseline Characteristics of Women Treated for a Hypertensive Emergency

Variable Preintervention (n5173) Postintervention (n5173) P

Age (y) 31 (17–45) 32 (19–47) .36*

Race
Black 31 (17.9) 28 (16.2) .55†
White 84 (48.6) 97 (56.1)
Asian 7 (4.1) 5 (2.9)
Other or not documented 51 (29.5) 43 (24.9)
Ethnicity
Hispanic or Latina 45 (26.0) 36 (20.8) .57†
Not Hispanic or Latina 126 (72.8) 134 (77.5)
Other or not documented 2 (1.2) 3 (1.7)
Nulliparous 68 (39.3) 76 (43.9) .45†
Multiple gestation (n5173) 9 (5.2) (n5171) 9 (5.3) 1.00†
BMI at 1st prenatal visit (kg/m2) (n5159) 31.3 (17.7–52.9) (n5166) 29.8 (18.6–59.0) .52‡
Diabetes
Gestational 24 (13.9) 22 (12.7) .95†
Pregestational 4 (2.3) 5 (2.9)
Chronic hypertension (n5173) 50 (28.9) (n5170) 48 (28.2) .91†
Prescribed antihypertensive 27 (54.0) 33 (68.8) .15†
History of preeclampsia 23 (13.4) 20 (11.6) .63†
BMI, body mass index.
Data are median (range) or n (%) unless otherwise specified.
* Student t test.
†
Fisher exact test.
‡
Wilcoxon rank-sum.

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Table 2. Clinical Characteristics of Women Treated for a Hypertensive Emergency

Variable Preintervention (n5173) Postintervention (n5173) P

Pregnant (n5124) (n5124)

Gestational age (wk) 36 (21–41) 35 (22–41) .32*
Postpartum (d) (n549) 6 (3–32) (n549) 7 (3–22) .16*
Chief complaint on presentation
Hypertension† 90 (52.0) 84 (48.6) .79‡
Neurologic symptoms 29 (16.8) 27 (15.6)
Labor symptoms 21 (12.1) 28 (16.2)
Shortness of breath 11 (6.4) 9 (5.2)
Gastrointestinal symptoms 9 (5.2) 10 (5.8)
Decreased fetal movement 1 (0.58) 4 (2.3)
Other 12 (6.9) 11 (6.4)
Initial laboratory values (n5161) (n5160)
UPC ratio greater than 0.1 83 (51.6) 79 (49.4) .74‡
Serum creatinine (mg/dL) 0.67 (0.47–5.3) 0.69 (0.40–1.7) .04*
AST (international units/mL) 22 (9–140) 23 (9–1, 172) .95*
ALT (international units/mL) (n556) 34 (9–165) (n5129) 23 (5–1, 088) .03*
Hemoglobin (g/dL) 12.0 (6.0–15.6) 11.6 (7.3–16.3) .13*
Platelets (3103/microliter) 230 (106–700) 235 (29–665) .47*
Pulmonary edema 8 (4.6) 10 (5.8) .81‡
UPC, urine protein-to-creatinine ratio; AST, aspartate aminotransferase; ALT, alanine aminotransferase.
Data are median (range) or n (%) unless otherwise specified.
* Wilcoxon rank-sum.
†
At home or in-office.
‡
Fisher exact test.

additionally staffed by obstetrics and gynecology
resident housestaff (eight residents per training year),
certified nurse–midwives, and nurse practitioners.
The quality improvement initiative involved
several steps (Fig. 1). The obstetrics and gynecology
physician practice guideline and nursing policy for
gestational hypertension and preeclampsia were
revised. The nursing policy specifically outlines
acceptable BP monitoring procedures, including
patient positioning and appropriate cuff size and
application. The policy also mandates that any
severe-range BP reading obtained automatically be
confirmed with a manual measurement. Both docu-
ments were reviewed by physician and nursing leader-
ship and voted on for acceptance by the medical staff
before publication as a clinical resource on the hospi-
tal’s secure network. In conjunction with nursing edu-
cators, management aids (laminated posters and small
reference cards designed for staff to wear with their
hospital identification badge) outlining the obstetric
hypertensive emergency treatment algorithms were
developed for use in real-time clinical care (Fig. 2).
The management aids were intended to help staff rec-
ognize and communicate the presence of a hyperten-
sive emergency to facilitate more timely IV access and
treatment. Posters were placed in common areas and
adjacent to every clinical workstation in individual
treatment rooms within the emergency department.
The reference cards were distributed to all emergency
department staff during brief educational sessions
(approximately 10–15 minutes) conducted during
staff meetings or clinical work hours. During these
sessions, the principal investigator (R.J.F.) explained
the importance of treating acute-onset severe hyper-
tension in pregnant and postpartum women as an
emergency, reviewed the BP parameters to initiate
treatment as well as goal BP ranges after treatment,
and discussed the new treatment algorithms in detail.
Finally, the computerized physician order entry set
used for evaluation and treatment of gestational
hypertension and preeclampsia was updated. This
included changing the doses of antihypertensive
agents to reflect those contained in the ACOG treat-
ment algorithms (20, 40, or 80 mg IV labetalol; 5 or
10 mg IV hydralazine, and 10 or 20 mg oral nifedi-
pine) and also added instructions for how often to
provide consecutive doses of each of the three drugs,
how often to monitor the patient’s BP during and after
treatment, and goals for BP control (maintain between
140–150 and 90–100 mm Hg). Each consecutive
antihypertensive dose required a clinician order and
could not be administered automatically by nursing
staff. The laboratory section was also updated to
include assessment of serum alanine aminotransferase
in addition to aspartate aminotransferase (other labo-
ratory tests included in the order set were complete

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Table 3. Outcomes of Pregnant Women Treated for a Hypertensive Emergency

Preintervention Postintervention
Variable (n5124) (n5124) P

Gestational age at delivery (wk) 36 (21–41) 36 (25–41) .58*

Nonreassuring fetal heart tones during initial BP stabilization (n5120) 3 (2.5) (n5119) 4 (3.4) .72†
Treatment side effects
Hypotension (BP 100/60 mm Hg or less) 17 (13.7) 12 (9.7) .43†
Tachycardia (pulse 110 bpm or greater) 6 (4.8) 2 (1.6) .28†
Headache 72 (58.1) 41 (33.1) ,.001†
Latency to delivery (d) 1 (0–43) 1 (0–76) .70*
Hospital admission 119 (96) 121 (98) .72†
Length of stay (d) 4 (1–20) 5 (1–24) .17*
Visits for hypertensive emergency (pregnant or 6 wk postpartum or (n5123) 1 (1–4) (n5124) 1 (1–5) .29*
less)
Received magnesium 97 (78) 95 (77) .88†
Received betamethasone (if 24–34 wk of gestation) (n542) 40 (95) (n549) 49 (91) .46†
Severe laboratory abnormalities
Platelet count less than 1003103/microliter 8 (7) 15 (12) .13†
Creatinine greater than 1.1 mg/dL 3 (2) 9 (7) .08†
AST or ALT 60 international units/L or greater 19 (15) 25 (20) .32†
Pulmonary edema 7 (6) 5 (4) .77†
Adverse neurologic outcome‡ 0 2 (1.6) .49†
Fetal growth restriction 20 (16) 23 (19) .74†
Intrauterine fetal death 1 (0.8) 2 (1.6) .62†
BP, blood pressure; bpm, beats per minute; AST, aspartate aminotransferase; ALT, alanine aminotransferase.
Data are median (range) or n (%) unless otherwise specified.
* Wilcoxon rank-sum.
†
Fisher exact test.
‡
Seizure, stroke, or posterior reversible encephalopathy syndrome.

blood count with platelets, serum creatinine, and
urine protein-to-creatinine ratio). All steps of the qual-
ity improvement initiative were completed by Decem-
ber 2015.
Pregnant (20 weeks of gestation or greater) and
postpartum (6 weeks postpartum or less) women with
a hypertensive emergency (systolic BP 160 mm Hg
or greater, diastolic BP 110 mm Hg or greater, or
both) treatment initiated in the emergency depart-
ment of Women & Infants Hospital were eligible for
inclusion. Patients were assigned to preintervention
and postintervention groups, which spanned from
September 1, 2014, to September 30, 2015, and
December 1, 2015, to November 30, 2016, respec-
tively. Patients were identified for inclusion if they
received IV labetalol, IV hydralazine, or oral nifed-
ipine during their emergency department course. Pa-
tients who received antihypertensive medication but
were not severely hypertensive at the time of the
administration, or for another indication such as to-
colysis, were excluded. A single author (R.J.F.) col-
lected maternal demographic and treatment
characteristics as well as pregnancy and neonatal out-
come data by individual patient electronic chart
review. Treatment characteristics recorded included
all BP values from initial severe reading to goal BP
and the type, date, and time of each antihypertensive
agent administered. Blood pressure values were
manually entered into the electronic medical record
system by nursing staff. The timing of medication
administration was recorded automatically when
a patient’s wrist band was scanned, unless a manual
override was required. Double data entry was per-
formed to minimize error; data were initially re-
corded onto a paper data collection form and
subsequently transferred to an electronic database.
Missing data fields and outliers were reported to
the primary investigator before analysis for clarifica-
tion (ie, data truly missing from medical record, inad-
vertently not recorded, or entered inaccurately). If
a patient had multiple emergency department pre-
sentations for a hypertensive emergency, treatment
characteristics were collected from only the first epi-
sode of care to maintain data independence.
The a priori primary outcome was achievement
of goal BP (systolic BP 150 mm Hg or less and
diastolic BP 100 mm Hg or less) within an hour of
initial antihypertensive therapy (and maintained for at
least 2 hours). Based on direct clinical observation in
the unit, it was estimated that 40% of women would
achieve the primary outcome in the preintervention
group. To detect a 615% difference in the

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Table 4. Outcomes of Postpartum Women Treated for a Hypertensive Emergency

Preintervention Postintervention
Variable (n549) (n549) P

Gestational age at delivery (wk) 38 (22–41) 39 (22–41) .11*

Treatment side effects
Hypotension (BP 100/60 mm Hg or less) 8 (16.3) 3 (6.1) .19†
Tachycardia (pulse 110 bpm or greater) 2 (4.1) 2 (4.1) 1.00†
Headache 32 (65.3) 30 (61.2) .83†
Hospital admission 34 (69) 41 (84) .15†
Length of stay (d) 2 (1–4) 2 (1–4) .09*
Visits for hypertensive emergency (pregnant or 6 wk postpartum or 1 (1–2) 1 (1–2) .97†
less)
Received magnesium 26 (53) 30 (61) .54†
Severe laboratory abnormalities
Platelet count less than 1003103/microliter 0 1 (2) 1.00†
Creatinine greater than 1.1 mg/dL 1 (2) 0 .49†
AST or ALT 60 international units/L or greater 10 (21) 9 (18) .80†
Pulmonary edema 8 (16) 8 (16) 1.00†
Adverse neurologic outcome‡ 1 (2) 2 (4) 1.00†
Fetal growth restriction 7 (14) 4 (8) .52†
Intrauterine fetal death 0 1 (2) 1.00†
BP, blood pressure; bpm, beats per minute; AST, aspartate aminotransferase; ALT, alanine aminotransferase.
Data are median (range) or n (%).
* Wilcoxon rank-sum.
†
Fisher exact test.
‡
Seizure, stroke, or posterior reversible encephalopathy syndrome.

postintervention group, with a power of eighty per- formed using Fisher exact tests for categorical
cent and type 1 error of 5%, a sample size of 346 variables and Student t test or Wilcoxon rank-sum
women was required. Planned secondary outcomes tests for continuous variables. Nonparametric tests
included times from first severe-range BP to 1) first were used for data that were not normally distributed.
treatment and 2) achieving goal BP. Baseline charac- All tests were two-tailed, and a P value of ,.05 was
teristic and outcome data comparisons were per- used to define statistical significance.
Table 5. Treatment Characteristics of Women Treated for a Hypertensive Emergency

Preintervention Postintervention
Variable (n5173) (n5173) P

Primary outcome
Achieved goal BP within 60 min of 1st treatment (and maintained 71 (41.0) 82 (47.4) .28*
for 2 h)
Secondary outcomes
1st BP to 1st treatment (min) 30 (0–179) 29 (0–140) .058†
1st BP to achieving goal BP (min) 122 (11–1,004) 95 (12–587) .04†
Time between 1st and 2nd BPs (min) 26 (1–118) 25 (1–91) .02†
Within 15 min 33 (19.1) 39 (22.5) .51*
1st antihypertensive used
Intravenous 90 (52.0) 138 (79.8) ,.001*
Oral 83 (48.0) 35 (20.2)
IV labetalol 81 (46.8) 131 (75.7) ,.001*
IV hydralazine 9 (5.2) 7 (4.1)
Oral nifedipine 81 (46.8) 32 (18.5)
Oral labetalol 2 (1.2) 3 (1.7)
More than 1 type of antihypertensive agent (n599) 51 (51.5) (n598) 47 (47.9) .67*
Oral antihypertensive agent within 12 h of presentation 78 (45.1) 92 (53.2) .16†
BP, blood pressure; IV, intravenous.
Data are n (%) or median (range) unless otherwise specified.
* Wilcoxon rank-sum.
†
Fisher exact test.

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Table 6. Markers of Quality Improvement Intervention Protocol Adherence

Variable Preintervention (n5173) Postintervention (n5173) P

Secondary outcomes
Time between 1st and 2nd BPs (min) 26 (1–118) 25 (1–91) .02*
Within 15 min 33 (19.1) 39 (22.5) .51†
Treatment within 15 min 31 (17.9) 45 (26.0) .09†
IV labetalol dosing (n531) (n562)
20 mg/40 mg (1st, 2nd doses) 9 (29) 54 (87) ,.001†
40 mg/80 mg (2nd, 3rd doses) (n520) 3 (15) (n532) 19 (59) .002†
IV hydralazine dosing (n54) (n54)
5 mg/10 mg (1st, 2nd doses) 2 (50) 3 (75) 1.00†
Oral nifedipine dosing (n521) (n56)
10 mg/20 mg (1st, 2nd doses) 6 (29) 5 (83) .03†
BPs, blood pressures; IV, intravenous.
Data are median (range) or n (%) unless otherwise specified.
* Wilcoxon rank-sum.
†
Fisher exact test.

RESULTS groups (Table 3). Fewer pregnant women were docu-

Three hundred forty-six women were included (Fig.
3). There were equal numbers of pregnant (n5124)
and postpartum (n549) women in the preintervention
and postintervention groups. When baseline charac-
teristics of women treated before and after the inter-
vention were compared, there were no significant
differences (Table 1); maternal age, race–ethnicity,
parity, and pregnancy plurality were all similar. The
presence of comorbidities such as pre-existing or ges-
tational diabetes mellitus, chronic hypertension, and
history of preeclampsia were also similar between
groups. Of women with chronic hypertension, 54%
were prescribed an oral antihypertensive agent (labe-
talol, nifedipine, or methyldopa) at the time of their
emergency department presentation in the preinter-
vention group compared with 69% in the postinter-
vention group (P5.15).
The median gestational age (36 vs 35 weeks in the
preintervention and postintervention groups, respec-
tively) and number of days postpartum (6 vs 7 days in
the preintervention and postintervention groups,
respectively) at the time of first emergency depart-
ment presentation for treatment of hypertensive
emergency were also similar (Table 2). The most com-
mon chief complaint was hypertension, either at home
or in an outpatient office, followed by neurologic (eg,
headache) or labor symptoms. More women had both
aspartate aminotransferase and alanine aminotransfer-
ase measured (vs aspartate aminotransferase alone) on
initial laboratory assessment in the postintervention
group (n5129 vs n556 in the preintervention group).
Pulmonary edema at the time of initial presentation
was rare in both groups. Nonreassuring fetal heart
tones during BP stabilization were uncommon in both
mented to report a headache after treatment in the
postintervention group: 33% vs 58% (P,.001;
Table 3). There were otherwise no significant differ-
ences in maternal or neonatal outcomes between the
preintervention and postintervention groups for both
pregnant and postpartum women (Tables 3 and 4).
The primary outcome, the proportion of women
achieving goal BP within 60 minutes of initial therapy,
was not statistically different between groups with
41% achieving the outcome preintervention com-
pared with 47% postintervention (P5.28; Table 5).
Median time from first severe BP to first treatment
was unchanged (30 minutes preintervention vs 29 mi-
nutes postintervention, P5.058); however, median
time from first severe BP to achieving goal BP
decreased significantly (122 minutes vs 95 minutes,
P5.04). Intravenous labetalol and oral nifedipine
were used more often than IV hydralazine as an initial
antihypertensive agent both before and after the inter-
vention (Table 5). In the preintervention group, just
under half of women received oral nifedipine or IV
labetalol; after the project, there was a statistically sig-
nificant increase in the use of IV labetalol as the first
antihypertensive agent, increasing from 47% to 76%
(P,.001).
Several other secondary outcome measures were
evaluated to assess markers of quality improvement
intervention protocol adherence (Table 6). Median
time between first and second BP measurements
decreased (28 minutes preintervention vs 25 minutes
postintervention, P5.02); however, confirmation of
hypertensive emergency within 15 minutes was only
achieved in approximately 20% of women in either
group. The proportion of women treated within

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15 minutes was 18% preintervention compared with
26% postintervention (P5.09). Consecutive doses of
IV labetalol and oral nifedipine for persistent severe
hypertension were administered according to the
doses recommended by ACOG more often in the
postintervention group.
DISCUSSION
The quality improvement initiative studied failed to
achieve the primary outcome; there was no associa-
tion between the initiative and an increased pro-
portion of women achieving BP control within an
hour of obstetric hypertensive emergency treatment.
In fact, less than half of women achieved goal BP
within an hour of therapy before or after the
intervention. However, some changes in practice after
the intervention were noted. First, median time to
achieving goal BP after treatment was significantly
reduced. Additionally, more women were treated with
IV antihypertensive agents after the intervention,
suggesting timelier IV access establishment. Antihy-
pertensive treatments were also administered accord-
ing to the new ACOG dosage recommendations more
often in the postintervention group. These findings
suggest that, for the women included in this study,
staff used a more aggressive treatment approach after
the initiative.
The benefits of implementing evidence-based
guidelines and standardized protocols for treating
hypertension in pregnancy have been demonstrated
in prior work.8,9 von Dadelszen et al8 found an associ-
ation between use of standardized management guide-
lines in maternity hospitals in British Columbia and
decreased Provincial rates of adverse maternal and
perinatal outcomes. Similarly, Clark et al9 found
a decreased maternal death rate related to hypertensive
disorders in the 6 years after the introduction of
checklist-based disease-specific treatment protocols
directed at preventing death from postcesarean pulmo-
nary embolism, intracranial hemorrhage associated
with hypertensive crisis, and postpartum hemorrhage.
A contemporaneous study published by Shields et al10
in April 2017 showed a significant reduction in the
incidence of eclampsia and severe maternal morbidity
associated with improved hospital compliance with
state and national treatment guidelines for severe
hypertension in pregnancy. This publication resulted
from a large collaboration of 23 California hospitals
that received education and underwent monitoring
for compliance with three components of state and
national guidelines: 1) treatment of severe hypertension
within 1 hour of verification, 2) use of magnesium sul-
fate for patients with critically elevated BP, and 3) early
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postpartum follow-up (within 1 or 2 weeks of dis-
charge). The described findings are encouraging; the
use of consistent, evidence-based practices can signifi-
cantly improve the quality of patient care (reflected by
improved outcomes).
Although the present study was not powered to
detect a difference in adverse maternal or neonatal
outcomes, by rigorously evaluating treatment charac-
teristics and markers of protocol adherence, we were
able to assess for both changes in clinical practice and
identify areas for continued improvement. First,
elimination of barriers to confirming and communi-
cating the presence of obstetric hypertensive emer-
gency within 15 minutes should be identified and
addressed, because this would facilitate more timely
treatment. Next, streamlining the administration of
consecutive antihypertensive doses should be consid-
ered. In the current system, each consecutive dose
requires a separate clinician order. The safety of
reflexive nursing administration of consecutive doses
for refractory hypertension within the established
treatment algorithms should be evaluated. Finally,
administration of a long-acting antihypertensive agent
once a certain BP threshold is achieved should be
considered. This was not specifically included in the
protocol in the studied initiative, but could decrease
the time required for patients to achieve sustained BP
control.
The strengths of this study would first include the
multidisciplinary collaboration of physician, nursing,
and advanced practice providers on a quality
improvement intervention that led to changed clinical
practice. Next, the simplicity of the intervention
would make it easy to replicate in another center
and generalizable to other obstetric populations.
Additionally, study data were abstracted directly from
individual patient records and not limited to coding
data. Study limitations include the retrospective
nature of the data collection, which depends on
completeness and assumes accuracy of the medical
record. This study captured only patients who
received treatment for severe hypertension in the
emergency department and cannot comment on
treatment of patients with obstetric hypertensive
emergency on other hospital units. Given safety
protocols in place, it is unlikely that a significant
number of patients with hypertensive emergency went
untreated in the emergency department during the
study period. Finally, although the intervention
should be generalizable to other obstetric populations,
its use in emergency departments with different types
of health care providers or patient acuity levels may
yield different results.
Obstetric Hypertensive Emergency Treatment 857
 Safe and effective care of patients experiencing an
obstetric hypertensive emergency requires a shared
understanding of not only treatment strategy, but also
the urgency with which it should be applied amongst
all health care providers. This study suggests that
a simple, multidisciplinary treatment approach and
clinical management aids can improve some aspects
of obstetric hypertensive emergency treatment and
highlights the need for ongoing quality improvement
efforts.
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