Hypertension is a leading cause of maternal morbidity and mortality worldwide. Hypertensive disorders overall affect 5–10% of all pregnancies in the U.S. with preeclampsia specifically complicating about 3%.[1], [2], [3], [4] Between 1993 and 2014, the incidence of hypertensive disorders in pregnancy nearly doubled from 529 to 912 per 10,000 delivery hospitalizations.[5] This trend is believed to be related to increasing prevalence of predisposing conditions such as chronic hypertension, diabetes, obesity, and delayed childbearing.

A particularly dangerous hypertensive condition in pregnancy is acute-onset severe hypertension, which is defined as a systolic blood pressure of 160 mmHg or greater and/or a diastolic blood pressure of 110 mmHg or greater persistent for at least 15 minutes. Individuals with prolonged severe hypertension are at risk of serious adverse outcomes including intracranial hemorrhage, cardiovascular complications, and death.[6], [7]

As such, in Committee Opinion #767 the American College of Obstetricians and Gynecologists (ACOG) recommends that treatment be initiated as soon as possible with a goal of 30–60 minutes after confirming the severe range blood pressure.[8] Appropriate first-line medications are intravenous (IV) labetalol, IV hydralazine, or immediate release oral nifedipine.9-11 Additionally, given that standardized guidelines have been shown to improve clinical outcomes in obstetrics and beyond,[12], [13], [14] ACOG also recommends implementation of standardized order sets to expedite treatment and reduce adverse outcomes.

The objective of this study was to assess the effect of an antihypertensive pathway to improve treatment of severe hypertension in pregnancy and the postpartum period. Prior studies in the inpatient setting have found that implementation of a standardized protocol for blood pressure rechecks and semiautonomous treatment algorithms was associated with improved treatment rates.[15], [16] Additionally, education and regular compliance monitoring were also associated with higher protocol adherence and improved outcomes.[17] As such, we hypothesized that by implementing an antihypertensive pathway order set in addition to measuring compliance and staff education, we could improve treatment rates of severe hypertension and reduce time to antihypertensive administration. This study is particularly significant given that it takes place in the Southeast United States, a region known for having higher rates of hypertension and hypertension-related mortality.[18], [19]