Faculty Bibliography

OBJECTIVE:Obstetric hypertensive emergency is defined as having systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg, confirmed 15 min apart. ACOG recommends that acute-onset, severe hypertension be treated with first line-therapy (IV labetalol, IV hydralazine or PO nifedipine) within 60 minutes to reduce risk of maternal morbidity and mortality. Therefore, our objective was to identify barriers that lead to delayed treatment of obstetric hypertensive emergency. STUDY DESIGN/METHODS:A retrospective cohort study was performed comparing women appropriately treated within 60 minutes versus those with delay in first line therapy. We identified 604 patients with discharge diagnoses of chronic hypertension, gestational hypertension or preeclampsia using ICD-10 codes and obstetric antihypertensive usage in a pharmacy database at one academic institution from January 2017 - June 2018. 267 subjects (44.2%) experienced obstetric hypertensive emergency in the intrapartum period or within two days of delivery. 213 subjects 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 ran-sum and sample t-tests were used to compare the two 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<0.05. RESULTS:Of the 213 women, 110 (51.6%) had delayed treatment vs. 103 (48.4%) who were treated within 60 min. Patients who had delayed treatment were 3.2 times more likely to present with an initial BP in the non-severe range vs those who had timely treatment (OR=3.24, 95% CI:1.85-5.68). Timeliness of treatment was associated with presence or absence of preeclampsia symptoms-- patients without pre-eclampsia symptoms were 2.7 times more likely to have delayed treatment (OR=2.68, 95%CI:1.50-4.80). Patients with HTN emergencies that occurred overnight between 10pm-6am were 2.7 times more likely to have delayed treatment vs. those that occurred between 6am-10pm (OR 2.72, 95% CI: 1.27-5.83). Delayed treatment also had an association with race, with Caucasian patients being 1.8 times more likely to have delayed treatment (OR=1.79; 95% CI: 1.04-3.08). Patients treated under 60 min had a lower gestational age at presentation vs those with delayed treatment (34.6±5wk vs. 36.6±4wks, respectively, p <0.001). For every 1 week increase in gestational age at presentation, there was a 9% increase in the likelihood of delayed treatment (OR 1.11; 95%CI:1.04-1.19). Another factor associated with delay of treatment was presenting complaint of labor symptoms, which made patients 2.2 times as likely to experience treatment delay (OR=2.17; 95%CI: 1.07-4.41). CONCLUSION/CONCLUSIONS:Initial blood pressure in non-severe range, absence of preeclampsia symptoms, presentation overnight, Caucasian race, presenting complaint of labor symptoms, and increasing gestational age at presentation are barriers that lead to delay in treatment of obstetric hypertensive emergency. Quality improvement initiatives targeting these barriers should be instituted to improve timely treatment.

BACKGROUND:While elevated second trimester maternal serum alpha fetoprotein (msAFP) has been associated with adverse pregnancy outcomes, the utility of first trimester msAFP in predicting these outcomes is limited. Some laboratories have been including msAFP as part of the first trimester analyte screening for aneuploidy and preeclampsia, offering its potential utility in predicting pregnancy outcomes. OBJECTIVE:Our primary objective was to determine the association between elevated first trimester msAFP and preeclampsia, as well as ischemic placental disease (a composite of preeclampsia, fetal growth restriction and/or placental abruption). Secondary outcomes included early onset preeclampsia requiring delivery at <34 weeks gestation, fetal growth restriction, placental abruption, preterm delivery, fetal demise, and spontaneous abortion. STUDY DESIGN/METHODS:An IRB-approved multi-site retrospective cohort study was performed including all patients with first trimester msAFP as part of routine first trimester aneuploidy screening from April 2015-January 2017. Pregnancies with multiple gestations, known structural or chromosomal abnormalities, known malignancy, and incomplete delivery records were excluded. Delivery records were reviewed for baseline characteristics and adverse pregnancy outcomes. The optimal cut-off point for first trimester msAFP to predict these outcomes was assessed and an elevated msAFP was considered > 2.0 MoM. Fisher exact test and odds ratios were used to determine the association between elevated first trimester msAFP and adverse pregnancy outcomes. Spearman correlation coefficient assessed the relationship between first and second trimester msAFP. RESULTS:Of 1478 patients with first trimester msAFP, 1280 had complete records available for review (86.6%). There was no association demonstrated between elevated first trimester msAFP (> 2.0 MoM) and the primary outcome, overall preeclampsia (5.8% vs. 4.6%, OR 1.29, 95% CI 0.58, 2.91). However, there was an increased incidence of ischemic placental disease, 15.8% vs 7.7% (OR 2.26, 95% CI 1.33-3.87) in those with an elevated AFP. Also, elevated first trimester msAFP was associated with a higher incidence of fetal growth restriction (7.5% vs 2.3%, OR 3.40, 95% CI 1.56-7.42) and preterm birth (18.3% vs 10.3%, OR 1.95, 95% CI 1.18-3.21). Also, a positive correlation between first and second trimester msAFP was demonstrated (rho = 0.46, P< 0.0001). CONCLUSIONS:Elevated first trimester msAFP is associated with ischemic placental disease, fetal growth restriction, and preterm birth. This suggests that elevated msAFP may help to identify high risk pregnancies as early as the first trimester of pregnancy. Future studies are necessary to determine if addition of first trimester msAFP to existing algorithms can improve the early detection of ischemic placental disease.

We report a rare case of a 30-year-old female who had a long-standing history of middle aortic syndrome that was being managed nonsurgically. She presented with hypertension and buttock pain with plans to become pregnant. She underwent an aortoiliac bypass.