Several years ago, von Dadelszen and Magee astutely noted that delivery does not “cure” preeclampsia but initiates the process of recovery. Before complete recovery occurs, often there is evidence of a transient deterioration in key clinical parameters such as hypertension, thrombocytopenia and renal dysfunction. Thus, nearly 75% of maternal deaths associated with hypertensive disorders occur after birth with 41% occurring > 48 hours postpartum.15
For postpartum stroke, the period of highest risk occurs during the first 10- days after hospital discharge—58% of stroke cases occurred during this time.16 This included 53% of strokes among women with a known hypertensive disorder of pregnancy and 66% of strokes among patients with chronic hypertension without superimposed preeclampsia—the median times to presentation were 8.9 and 7.8 days, respectively. These data underscore the importance of close monitoring of patients with hypertensive disorders for the first 72 hours postpartum, reevaluating them within 7 to 10 days postpartum as recommended by the American College of Obstetricians and Gynecologists.17 Practices are encouraged to coordinate early postpartum care with blood pressure assessment in concert with patient education, the assurance of patient access to prescribed medication(s), and appropriate long-term care.18
Racial disparities in hypertension-related mortality
In comparison to US-born white women, nearly all other racial, ethnic and nativity groups face a greater risk of pregnancy-related mortality in the United States.19 Black women in the United States, in particular, are at significant risk of hypertension-related morbidity and mortality. Compared to white women, black women have nearly twice the incidence of preeclampsia (6.04 vs 3.75%), are more likely to suffer complications such as cardiac arrest, ARDS and heart failure and are over 3 times more likely to die.20,21 While variations in disease severity explain some of these disparities, differences in care delivery and variations in hospital quality can significantly impact risk of maternal death for black women.22
Focus on severe persistent hypertension
Emergent treatment of severe acute-onset persistent hypertension (systolic BP > 160 mmHg or diastolic BP > 110 mmHg sustained > 15 minutes) constitutes an important component of high-quality obstetric care. Even in the absence of proteinuria, sudden development of sustained severe hypertension causes significant risk of hemorrhagic stroke and death. An estimated 25% to 45% of maternal strokes occur among patients with preeclampsia, eclampsia or HELLP syndrome.23 Severe systolic blood pressure is a consistent feature present before the onset of stroke in over 90% of women with hypertensive disorders.24
When reviewing factors contributing to preventable preeclampsia-related deaths, multiple state mortality reviews have identified instances of delayed medical staff response to both worrisome maternal symptoms and vital signs and inadequate staff knowledge and treatment of severe hypertension.6,25 There has been a national call to action for clinical practices to implement standardized systems to identify and treat severe maternal hypertension and associated disorders.26,27 A progressive algorithm for treatment within 60 minutes of confirmed measurement is recommended such as illustrated in the most recent ACOG Committee Opinion and otherwise summarized in Table 1. Staff should be educated on the algorithm including contraindications (i.e. labetalol contraindicated with asthma, heart disease or congestive heart failure) and patients informed about the goals of therapy, side effects and safety of these medications for breastfeeding mothers.
The recently released consensus bundle for severe hypertension includes guidance not only for standardization of antihypertensive therapy, but also for other important components of care such as discharge criteria, readmission criteria and guidance for postpartum outpatient surveillance all of which should be tailored to the unique maternity care setting.27 Use of such standardized treatment practices or safety bundles for maternal hypertensive disorders can significantly improve pregnancy outcomes.6,28 Shields demonstrated that compliance with blood pressure treatment recommendations increased from 50% to over 90% with a structured quality improvement initiative across 23 facilities. Importantly, this resulted in a 43% reduction in eclampsia and a 17% reduction in severe maternal morbidity.29
The authors report no potential conflicts of interest with regard to this article.
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- Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9947):980-1004.
- Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-Related Mortality in the United States, 2011-2013. Obstet Gynecol. 2017;130(2):366-373.
- Zhang J, Meikle S, Trumble A. Severe maternal morbidity associated with hypertensive disorders in pregnancy in the United States. Hypertens Pregnancy. 2003;22(2):203-212.
- Ghulmiyyah L, Sibai B. Maternal mortality from preeclampsia/eclampsia. Semin Perinatol. 2012;36(1):56-59.
- Main EK, McCain CL, Morton CH, Holtby S, Lawton ES. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol. 2015;125(4):938-947.
- MacDorman MF, Declercq E, Cabral H, Morton C. Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues. Obstet Gynecol. 2016;128(3):447-455.
- Berg CJ, Atrash HK, Koonin LM, Tucker M. Pregnancy-related mortality in the United States, 1987-1990. Obstet Gynecol. 1996;88(2):161-167.
- Berg CJ, Chang J, Callaghan WM, Whitehead SJ. Pregnancy-related mortality in the United States, 1991-1997. Obstet Gynecol. 2003;101(2):289-296.
- Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125(1):5-12.
- Building U.S. Capacity to Review and Prevent Maternal Deaths. Report from 9 maternal mortality review committees. http://reviewtoaction.org/Report_from_Nine_MMRCs. 2018.
- Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol. 2009;113(6):1299-1306.
- Callaghan WM. State-based maternal death reviews: assessing opportunities to alter outcomes. Am J Obstet Gynecol. 2014;211(6):581-582.
- Hernandez L. Pregnancy-Related Deaths Due to Hypertensive Disorders 1999-2012. Florida Depart. of Health.
- von Dadelszen P, Magee LA. Preventing deaths due to the hypertensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol. 2016;36:83-102.
- Too G, Wen T, Boehme AK, et al. Timing and Risk Factors of Postpartum Stroke. Obstet Gynecol. 2018;131(1):70-78.
- American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy, American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Washington, DC: American College of Obstetricians and Gynecologists; 2013.
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- Howell EA, Egorova NN, Balbierz A, Zeitlin J, Hebert PL. Site of delivery contribution to black-white severe maternal morbidity disparity. Am J Obstet Gynecol. 2016;215(2):143-152.
- Lanska DJ, Kryscio RJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke. 2000;31(6):1274-1282.
- Martin JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005;105(2):246-254.
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- ACOG Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2015;125(2):521-525.
- Bernstein PS, Martin JN, Barton JR, et al. National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol. 2017;130(2):347-357.
- Cleary KL, Siddiq Z, Ananth CV, et al. Use of Antihypertensive Medications During Delivery Hospitalizations Complicated by Preeclampsia. Obstet Gynecol. 2018;131(3):441-450.
- Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HL. Early standardized treatment of critical blood pressure elevations is associated with a reduction in eclampsia and severe maternal morbidity. Am J Obstet Gynecol. 2017;216(4):415.e411-415.e415.
- Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol. 2005;105(2):402-410.
- Altman D, Carroli G, Duley L, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet. 2002;359(9321):1877-1890.
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