Original Research ajog.

org

1 OBSTETRICS 56
2 57
3 Early standardized treatment of critical blood pressure 58
4
5
elevations is associated with a reduction in eclampsia 59
60
6 and severe maternal morbidity 61
7 Q9
62
Laurence E. Shields, MD; Suzanne Wiesner, RN, MBA; Catherine Klein, RN, CNM; Barbara Pelletreau, RN, MPH;
8 Q1
63
Herman L. Hedriana, MD
9 64
10 65
11 66
12 BACKGROUND: Hypertensive disorders of pregnancy result in sig- pressure, preeclampsia, or superimposed preeclampsia with severe fea- 67
nificant maternal morbidity and mortality. State and national guidelines tures. Of this group, 1520 had a sustained critical blood elevation. Initial 68
13
have been proposed to increase treatment of patients with hypertensive compliance with treatment recommendations was low (50.5%) and
14 69
emergencies or critically elevated blood pressures. There are limited data increased to >90% after April 2016 (P < .001). Compliance with utili-
15 70
available to assess the impact of these recommendations on maternal zation of intravenous blood pressure medication increased by 33.2%, from
16 71
morbidity. a baseline of 57.1-90.3% (P < .01) during the last 6 months of moni-
17 OBJECTIVE: The purpose of this prospective quality improvement toring. Compliance with utilization of magnesium sulfate increased by
72
18 project was to determine if maternal morbidity would be improved using a 10.8%, from a baseline of 85.4-96.2% (P < .01). The incidence of 73
19 standardized approach for treatment of critically elevated blood pressures. eclampsia declined by 42.6% (1.15  0.15/1000 to 0.62  0.09/1000 74
20 STUDY DESIGN: In all, 23 hospitals participated in this project. births). Severe maternal morbidity decreased by 16.7% from 2.4  0.10% 75
21 Treatment recommendations included the use of an intravenous blood to 2.0  0.15% (P < .01). 76
22 pressure medication and magnesium sulfate when there was a sustained CONCLUSION: We noted 3 important findings: (1) compliance with 77
23 blood pressure of
160 mm Hg systolic and/or
110 mm Hg diastolic. state and national treatment guidelines is low without monitoring; (2) high 78
24 Compliance with the metric recommendations was monitored based on levels of compliance can be achieved in a relatively short period of time; 79
25 the number of patients treated with an intravenous blood pressure and (3) early intervention with intravenous blood pressure medication and 80
26 medication, use of magnesium sulfate, and if they received a timely magnesium sulfate for verified sustained critical maternal blood pressures 81
27 postpartum follow-up appointment. The metric was scored as all or none; resulted in a significant reduction in the rate of eclampsia and severe 82
28 missing any of the 3 metric components was considered noncompliant. maternal morbidity. The reduction in the rate of eclampsia could only 83
29 From January through June 2015 baseline data were collected and partially be attributed to the increase in the use of magnesium sulfate, 84
30 hospitals were made aware that ongoing monitoring of compliance would suggesting an additive or synergistic effect of the combined treatment of 85
31 begin in July 2015 through June 2016. The primary outcomes were an antihypertensive medication and magnesium sulfate on the rate of 86
32 composite metric compliance, the incidence of eclampsia per 1000 births, eclampsia and severe maternal morbidity. 87
33 and severe maternal morbidity. 88
34 RESULTS: During the 18 months of this study there were 69,449 births. Key words: blood pressure treatment, eclampsia, preeclampsia, severe 89
35 Within this population, 2034 met criteria for a critically elevated blood maternal morbidity 90
36 91
37 92
Introduction Congress of Obstetricians and Gynecol- critical blood pressures by recommend-
38 93
Globally, hypertensive disorders of ogists (ACOG) published their Executive ing that patients be acutely treated if
39 94
pregnancy continue to be a signicant Summary on Hypertension in Preg- blood pressure values were sustained,
40 95
contributor to maternal mortality and nancy.4 This document redened certain dened as persistent values
15 minutes
41 96
morbidity.1 While these adverse out- aspects of the denition of hypertensive apart. They also recommended that
42 97
comes are more pronounced in devel- disorders in pregnancy as well as treat- these patient be treated with magnesium
43 98
oping nations, they continue to be one of ment guidelines. The summary sup- sulfate for seizure prophylaxis. In
44 99
the main contributors to maternal ported treatment guidelines for use of an attempt to reduce postpartum
45 100
mortality and morbidity in the United medication for hypertensive emergen- morbidity, early follow-up was likewise
46 101
States.2,3 In 2013, the American cies where systolic and/or diastolic blood recommended.
47 102
pressure are >160/110 mm Hg. These As part of the California Maternal
48 103
Cite this article as: Shields LE, Wiesner S, Klein C, et al. recommendations were further rened Quality Care Collaborative (CMQCC)
49 104
Early standardized treatment of critical blood pressure in national guidelines (Council on Pa- toolkit implementation, a group of 24
50 105
elevations is associated with a reduction in eclampsia tient Safety in Womens Health Care)5 hospitals, comprising both academic
51 and severe maternal morbidity. Am J Obstet Gynecol 106
and state toolkits from California,6 medical centers and community hospi-
52 2017;volume:x.ex-x.ex. 107
New York,7 and Florida.8 Both the na- tals, agreed to trial the toolkit at their
53 108
0002-9378/$36.00 tional and state organizations took a institutions. These 24 hospitals were
54 2017 Elsevier Inc. All rights reserved. 109
http://dx.doi.org/10.1016/j.ajog.2017.01.008 more aggressive approach toward treat- collectively known as the Preeclampsia
55 110
ment of hypertensive emergencies or CMQCC. One component of the

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111 167
112 collaborative was to test their ability to reduction in the rate of eclampsia. and was continued for 1 year. Moni- 168
113 follow the toolkit guidelines for blood Similar to the approach that we took in toring was divided into 2 time frames, 169
114 pressure verication and treatment of a our MEWT trial, patients with blood each 6 months in duration. The 23 170
115 conrmed critical blood pressure within pressures elevated
160 mm Hg systolic hospitals included vary in annual de- 171
116 1 hour. Their data suggested that only and/or
110 mm Hg diastolic were livery volume from 140 to nearly 5000 172
117 41% of sites met this goal.9 This hospital requested to have the blood pressure births. Data were prospectively collected 173
118 collaborative went on to show that veried within 15-20 minutes. If the at each hospital and collated monthly at 174
119 improving the number of patients blood pressure elevations were sus- the central perinatal safety ofce. 175
120 treated within 1 hour was associated tained, it was considered a critical blood Compliance for an individual case was 176
121 with a reduction in severe maternal pressure and treatment with intravenous rated as all or none, based on the utili- 177
122 morbidity (SMM).9 Similarly, treating hydralazine or labetalol using a standard zation of all elements or absence of
1 of 178
123 critical blood pressures as part of a treatment algorithm was recom- the 3 elements being monitored. For 179
124 maternal early warning trigger (MEWT) mended.6,7,10 Blood pressures were example, if a patient received magne- 180
125 tool resulted in a signicant reduction in rechecked prior to medication adminis- sium but not antihypertensive medica- 181
126 the rate of eclampsia.10 The purpose of tration and, if <160 mm Hg systolic and tion if indicated, the case would be 182
127 this investigation was to determine if 110 mm Hg diastolic, antihypertensive considered noncompliant. Similarly, if 183
128 using key elements from CMQCC and medication was not administered unless postpartum follow-up was not made in 184
129 the Council on Patient Safety in a critical value was reached later in the the specied time period, the case would 185
130 Womens Health Care guidelines would course of the patients hospitalization. be rated as noncompliant. System and 186
131 reduce the incidence of eclampsia and All patients meeting blood pressure individual hospital compliance status 187
132 SMM within a large group of commu- criteria, regardless of the underlying were presented in monthly perinatal 188
133 nity hospitals. We focused on 3 key ele- cause of their hypertension, were ex- safety World Wide Webebased meet- 189
134 ments: (1) treatment of critically pected to be treated with magnesium ings. Primary outcome data were the 190
135 elevated blood pressures within 1 hour of sulfate. Patients with preeclampsia with rates of eclampsia per 1000 births, the 191
136 verication; (2) use of magnesium sul- severe features or superimposed pre- rate of Centers for Disease Control and 192
137 fate in the presence of critically elevated eclampsia with severe features were also Preventionedened SMM (CDC- 193
138 blood pressures regardless if other treated with magnesium sulfate per SMM) per 100 births,11 and overall 194
139 criteria for preeclampsia were present; ACOG guidelines.4 Patients with pre- compliance with the all-or-none metric. 195
140 and (3) early postpartum follow-up eclampsia without severe features could Three time periods were used for anal- 196
141 assessment. be treated with magnesium sulfate at the ysis: (1) baseline, from January through 197
142 discretion of their physician. The nal June 2015; (2) monitoring phase I, July 198
143 Materials and Methods aspect of the process was to make sure all 2015 through December 2015; and (3) 199
144 This study used deidentied and aggre- postpartum patients with a diagnosis of a monitoring phase II, January through 200
145 gate data as part of a clinical patient hypertensive disorder of pregnancy were June 2016. To establish a benchmark for 201
146 safety monitoring program that was seen within 2 weeks of discharge if they evaluating data from the baseline time 202
147 approved by Dignity Healths Institu- had a hypertension diagnosis, or within period, rates of CDC-SMM and the fre- 203
148 tional Review Board. In May 2014, the 23 1 week postpartum if they required quency of eclampsia were calculated 204
149 hospitals included in this study were antihypertensive medication during from data collected from the preceding 2 205
150 provided with recommendations for the their admission. Retrospective baseline years (2013 through 2014) and used for 206
151 management and treatment of pre- data were collected from January 2015 comparison. 207
152 eclampsia and critically elevated blood through June 2015 to determine baseline Data were analyzed by comparing 208
153 pressures, which were consistent with compliance with the 3 metric compo- differences between independent pop- 209
154 CMQCC guidelines designed to reduce nents (blood pressure treatment, mag- ulations using an online statistical anal- 210
155 maternal morbidity and mortality.6 nesium sulfate treatment, and follow-up ysis tool (Vassarstats.net; Richard Lowry, Q3 211
156 Detailed monitoring of utilization of guidelines). During this same time MD, Vassar College, Poughkeepsie, NY). 212
157 these recommendations was not carried period from January through June 2015, Condence intervals (90th centile) were 213
158 out at that time. During this same time hospitals were notied that monitoring calculated using the online statistical 214
159 period we initiated a pilot project at 6 of compliance and outcomes monitoring analysis tool Condence Interval 215
160 hospitals, not include in this report, to were going to begin in July 2015. Calculator for Proportions (https:// 216
161 test a MEWT tool.10 The MEWT tool Educational presentations were made to www.mccallum-layton.co.uk). 217
162 had recommendations for treatment of all of the obstetrics and gynecology de- 218
163 critically elevated blood pressures iden- partments through the hospital systems Results 219
164 tical to those evaluated in this project. annual perinatal meeting, monthly During the 18 months of this project, 220
165 Data from the MEWT trial sites sug- perinatal safety meetings, and webinar there were a total of 69,449 births. Of 221
166 gested the use of these recommendations presentations. Monitoring of compli- these, 2034 met criteria for treatment 222
was associated with a signicant ance began prospectively in July 2015 with magnesium sulfate. Blood Q4

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223 279
224 TABLE 280
225 Population characteristics and outcome data 281
226 282
227 Baseline Monitoring phase I Monitoring phase II N 283
228 Deliveries 22,506 24,409 22,534 69,449 284
229 Met criteria for treatment with magnesium sulfate 589 (2.6%) 646 (2.6%) 799 (3.5%) 2034 (2.9%) 285
230 286
Appropriately treated with magnesium sulfate 503 (85.4%) 597 (92.0%) 769 (96.2%) P < .01
231 287
232 Met criteria for acute blood pressure treatment 504 (2.2%) 490 (2.0%) 526 (2.3%) P .5 288
233 Appropriately treated with hypertensive medication 287 (56.9%) 388 (79.2%) 474 (90.1%) P < .01 289
234 Blood pressure medication used 290
235 291
Labetalol 44.2% 53.8% 63.8% P < .01
236 292
237 Hydralazine 38.6% 30.2% 26.0% P < .01 293
238 Oral labetalol or nifedipine 15.9% 16.0% 10.2% P .02 294
239 Shields et al. Standardized treatment of critical blood pressure. Am J Obstet Gynecol 2017. 295
240 296
241 297
242 298
243 pressure was not sustained 514 patients the rate of acute blood pressure treat- births in phase I of monitoring. During 299
244 (25.3%) and they did not require ment for critical blood pressures phase II of monitoring, the rate of 300
245 treatment with an antihypertensive increased by 33.2%, from a baseline eclampsia had decreased by a total of 301
246T1 medication (Table). The average pre- rate of 56.9% of cases, to 79.2% during 42.6% relative to 2013 through the 302
247 treatment systolic blood pressure was phase I of monitoring, to 90.2% during baseline time period, to a rate of 0.62  303
248 172.9  14.0 mm Hg (range 138-258 the 6 months of phase II monitoring 0.09/1000 births (P .02) (Figure). The F1 304
249 mm Hg) and the average pretreatment (Table) (P < .01). Compliance with all rate of SMM was not different between Q5 305
250 diastolic pressure was 102.3  13.9 3 metric components increased from years 2013 through 2014 and the base- 306
251 mm Hg (range 71-153 mm Hg). Iso- 50.5% at baseline to an average of line time period: 2.4  0.08% and 2.4  307
252 lated systolic blood pressure was more 88.5% during phase II of monitoring 0.10%, respectively. The rate of CDC- 308
253 frequently elevated, noted in 75.8% of (P < .01) (Table). During the last 3 SMM declined by 16.7% between 2013 309
254 cases while isolated diastolic blood months of phase II monitoring the rate through the baseline time period and 310
255 pressure was infrequent, noted in only of compliance increased to 92.8%. phase II of monitoring (2.4  0.10% vs 311
256 5.3% of cases. The combination of Over the course of the project there 2.0  0.15%, P <.01) (Figure). Similarly, 312
257 elevated systolic and diastolic blood was a signicant shift in the preference the rate of SMM in the group of 2034 313
258 pressure was noted in 18.9% of cases. of blood pressure medications used. patients with a diagnosis of critical blood 314
259 As noted above, treatment with mag- During the baseline time period pressure elevations, preeclampsia with 315
260 nesium sulfate was recommended for intravenous labetalol was the most severe features, or superimposed pre- 316
261 all patients meeting blood pressure frequent antihypertensive agent used eclampsia severe features decreased by 317
262 criteria as well as those who had other (44.2%) while hydralazine was utilized 28.5%, from a rate of 10.5  2.0% at 318
263 criteria of preeclampsia with severe slightly less frequently (38.6%). During baseline to 7.5  1.5% during phase II of 319
264 features or superimposed preeclampsia phase II of monitoring the rate of hy- monitoring (P <.05). When the number 320
265 with severe features. The rate of dralazine use had declined to 26.0% of of eclampsia patients were removed 321
266 appropriate magnesium sulfate utili- cases and labetalol use increased to from the analysis the rate of CDC-SMM 322
267 zation increased by 10.9%, from 85.4% 63.8% of cases (P < .01) (Table). was still signicantly reduced: P < .01. 323
268 of cases during the baseline time During the years 2013 through 2014, During course of the study there was a 324
269 period, to 92.0% in phase I of moni- there were a total of 95,393 deliveries and modest increase in the rate of sponta- 325
270 toring, and to 96.2% during phase II of a total of 110 cases of eclampsia or 1.15 neous vaginal delivery (63.5-64.7%, P < 326
271 monitoring (Table) (P < .01). A total  0.15/1000 births. During the 6-month .01) and a decrease in the rate of opera- 327
272 of 1520 (74.7%) of patients had a baseline time period, when resources tive vaginal deliveries (4.1-3.1%, P < 328
273 sustained blood pressure elevation were available and recommendations for .01), while total (32.4-32.1%) and pri- 329
274 requiring treatment with an antihy- treatment were in place but monitoring mary (16.4-16.1%) cesarean delivery 330
275 pertensive medication. At baseline, of compliance was not yet occurring, the rates remained unchanged (P .5 and 331
276 nonutilization of an antihypertensive rate of eclampsia remained unchanged at P .3, respectively). There was no 332
277 agent was the most common reason for 1.16  0.12/1000 births. After the initi- change in the rate of neonatal intensive 333
278 noncompliance, noted in 42.9% of ation of monitoring, the rate of care unit admission or neonatal inten- 334
cases. During the course of the study, eclampsia decreased to 0.90  0.10/1000 sive care unit admissions for infants with

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335 391
336 another patient population primarily 392
FIGURE
337 dened by critical blood pressure eleva- 393
---
338 tion. Our data suggest that combined 394
339 2.5 treatment with magnesium sulfate and 395
340 intravenous blood pressure medication 396
Rate of Eclampsia /1000 Births

p<0.01 reduces the rate of severe morbidity and

341 397
Rate of SMM /100 BIrhts

342 2 that the reduction in severe morbidity 398

343 persisted after excluding cases of 399
344 eclampsia from the calculation of CDC- 400
1.5 SMM.
345 401
346 During the course of the study there 402
347 was an increase in the number of patients 403
1
348 p=0.02 who met criteria for treatment with 404
349 magnesium sulfate. The exact cause of 405
350 0.5 this change is not clear, but may reect 406
351 an increased recognition of patients 407
352 meeting criteria for preeclampsia with 408
0 severe features. Of those meeting criteria
353 409
2013-2014 Baseline Monitoring Phase Monitoring Phase for treatment with magnesium sulfate
354 410
I II we noted a modest, 10.8% increase in the
355 411
Eclampsia CDC-defined SMM use of magnesium sulfate relative to the
356 412
357 Rate of eclampsia per 1000 births and rate of Centers for Disease Control and Prevention (CDC)- 33.2% increase in the use of a blood 413
358 Q8 defined severe maternal morbidity (SMM) per 100 births. pressure medication. The modest in- 414
359 Shields et al. Standardized treatment of critical blood pressure. Am J Obstet Gynecol 2017. crease in the use of magnesium in this at- 415
360 risk population in phase II of monitoring 416
361 would have been expected to produce 417
362 birthweights >2500 g (P .24 and P with data, albeit at a different magnitude, about a 17% reduction in eclampsia17 418
363 .16, respectively). from developing countries where the and not the 42.6% reduction we noted. 419
364 improvements in maternal mortality in While this study was not designed to 420
365 Comment patients with hypertensive disorders of evaluate this nding it would suggest 421
366 The primary goal of this project was to pregnancy can only partially be attrib- that the combination of magnesium 422
367 determine if using a relatively simple uted to the use of magnesium sulfate.12 sulfate and antihypertension treatment 423
368 approach to management of critically Prior to the recently revised recom- is more effective than magnesium sulfate 424
369 elevated blood pressures would result in mendations for the treatment of hyper- alone, with an estimated number needed 425
370 a measurable reduction in key maternal tensive disorders of pregnancy from state to treat of 29 to prevent each case of 426
371 outcome measures. This management and national organizations, the rate of eclampsia. Although recommendations 427
372 approach is consistent with recent rec- maternal mortality related to hyperten- for treatment and follow-up in our 428
373 ommendations from CMQCC,6 the sive disorders of pregnancy has not hospitals were based on state and na- 429
374 Council on Patient Safety in Womens changed in >20 years.3,13,14 In an effort tional recommendations and, in cases of 430
375 Health Care,5 and other state organiza- to change this trend, ACOG,4 CMQCC,6 preeclampsia, by ACOG,18 the number 431
376 tions.7,8 We noted that both the rate of New York,7 Florida,8 and the Council on of patients receiving care consistent with 432
377 eclampsia, one of the most signicant Patient Safety in Womens Health Care5 these recommendations was low, 50.5% 433
378 complications of hypertensive disorders emphasized that pregnant women at baseline. This was consistent with 434
379 of pregnancy, and the rate of SMM were should have acute blood pressure treat- previous ndings from the Preeclampsia 435
380 reduced. The reduction in eclampsia was ment and magnesium sulfate if they CMQCC.9 After notifying all facilities 436
381 similar to our previous report using the meet the criteria for critical blood pres- that monitoring was going to take place 437
382 same treatment algorithm that was a sure elevation dened as a sustained as well as providing staff and physician 438
383 component of our MEWT tool.10 The elevation
160 mm Hg and/or
110 education, compliance with all 3 metrics 439
384 reduction in the rate CDC-SMM mm Hg diastolic. These blood pressure increased to >90% in <1 year. These 440
385 remained when eclampsia was removed values were primarily chosen as they ndings suggest that ongoing moni- 441
386 from the calculation, suggesting that the corresponded to predicted reductions in toring of patient quality improvement 442
387 increase in utilization of magnesium incidence of maternal stroke.15 However, measures and key elements of patient 443
388 sulfate and treatment of critically the rate of SMM in patients with critical care are essential for success. These 444
389 elevated blood pressures resulted in blood pressure elevation is high, 10.5% conclusions are consistent with the 445
390 other improvements in maternal out- in this study. Kilpatrick et al16 noted a recent observation that merely produc- 446
comes. These ndings are consistent similar high rate of SMM (8.8%) in a ing a recommendation for treatment of a

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447 503
448 specic condition does not produce a In summary, we noted signicant of preeclampsia reduces maternal morbidity.
504
449 change in outcome.19 improvements in the rate of eclampsia Am J Obstet Gynecol 2015;212:S69.
505
10. Shields LE, Wiesner S, Klein C,
450 We noted that the blood pressure and SMM with the use of a simple Pelletreau B, Hedriana HL. Use of maternal 506
451 medication choice shifted during the intervention strategy related to blood early warning trigger tool reduces maternal 507
452 course of the study from a relatively pressure treatment and the use of mag- morbidity. Am J Obstet Gynecol 2016;214:
508
453 equal mix of intravenous labetalol and nesium sulfate. These data strongly 527.e1-6.
509
hydralazine to predominantly intrave- support recent changes to state and na- 11. Callaghan WM, Mackay AP, Berg CJ. Iden-
454 tication of severe maternal morbidity during 510
455 nous labetalol. Although specic data tional guidelines for treatment of pa- delivery hospitalizations, United States, 1991- 511
456 related to this shift were not recorded, tients with critical blood pressure 2003. Am J Obstet Gynecol 2008;199:133. 512
457 many of the hospitals could not initially elevations in pregnancy. This study was e1-8.
513
458 use intravenous labetalol on their labor carried out in a large group of commu- 12. Goldenberg RL, Jones B, Grifn JB, et al.
514
and delivery units until they had nity hospitals with annual birth volumes Reducing maternal mortality from preeclampsia
459 and eclampsia in low-resource countriesewhat 515
460 changed hospital policies allowing the from 140 to nearly 5000, suggesting that should work? Acta Obstet Gynecol Scand 516
461 use of labetalol outside of the intensive the intervention and outcomes noted 2015;94:148-55. 517
462 care or telemetry units. This should be a here are likely applicable to most ma- 13. MacKay AP, Berg CJ, Atrash HK. Preg-
518
463 priority at centers attempting to change ternity units within the United States or nancy-related mortality from preeclampsia
519
464 their acute management of patient with similar health care systems. n and eclampsia. Obstet Gynecol 2001;97:
520
533-8.
465 critical blood pressures. 14. California Maternal Quality Care Collabora- 521
466 Our study has a number of key References tive. The California pregnancy-associated mor- 522
467 strengths but is also not without limita- 1. Duley L. The global impact of pre-eclampsia tality review, report from 2002-2003 Maternal
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468 15. Martin JN Jr, Thigpen BD, Moore RC, 524
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469 The CHIPS randomized controlled trial (control Rose CH, Cushman J, May W. Stroke and se- 525
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528
473 the interventions tested here would have 3. Creanga AA, Berg CJ, Ko JY, et al. Maternal 16. Kilpatrick SJ, Abreo A, Greene N, et al. Se-
529
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476 this approach are cost and logistics of 4. American College of Obstetricians and Gy- e1-7. 532
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533
478 that intervention study in the United Pregnancy. Hypertension in pregnancy. Report women with pre-eclampsia, and their babies,
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States with close to 70,000 patients will of the American College of Obstetricians and benet from magnesium sulphate? The Magpie
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482 prospective quality improvement pro- 5. Council on Patient Safety in Womens Health Emergent therapy for acute-onset, severe
538
483 cess, while not as robust at a randomized Care. Severe hypertension in pregnancy. Avail- hypertension with preeclampsia or eclampsia.
539
controlled trial, offers the opportunity to able at: http://safehealthcareforeverywoman. Committee opinion no. 514. Obstet Gynecol
484 org/patient-safety-bundles/severe-hypertension- 2011;118:1465-8. 540
485 rapidly test an intervention strategy in a 19. Bailit JL, Grobman WA, McGee P, et al. 541
in-pregnancy. Accessed Nov. 1, 2015.
486 large cohort with relatively rapid assess- 6. Druzin ML, Shields LE, Peterson NL, et al. Does the presence of a condition-specic ob- 542
487 ment of results. Additional limitations of Preeclampsia toolkit: improving health care stetric protocol lead to detectable improve-
543
488 this large project were related to data response to preeclampsia California Maternal ments in pregnancy outcomes? Am J Obstet
544
collection. While we prospectively Quality Care Collaborative toolkit to transform Gynecol 2015;213:86.e1-6.
489 maternity care; developed under contract #11- 545
490 collected data on key maternal in- 546
10006 with the California Department of Public
terventions we were limited to pre- Author and article information
491 Health; Maternal Child and Adolescent Health 547
dened coded data for the collection of Division; published by the California Maternal From Maternal-Fetal Medicine, Marian Regional Medical
492 Center, Santa Maria (Dr Shields); Department of Patient 548
493 outcome measures and did not have Quality Care Collaborative, November 2013.
549
7. New York State Department of Health. Hy- Safety, Dignity Health, San Francisco (Dr Shields, Ms
494 detailed patient-level information such Wiesner, Ms Klein, and Ms Pelletreau); and Sacramento 550
pertensive disorders in pregnancy. Available at:
495 as magnesium toxicity or gestational age Maternal-Fetal Medicine Medical Group Inc, Sacramento 551
https://www.health.ny.gov/professionals/proto
496 at birth. In this study, we requested that cols_and_guidelines/hypertensive_disorders/ (Dr Hedriana), CA.
552
497 blood pressure be lowered and main- 2013_hdp_executive_summary.pdf. Accessed Received Nov. 14, 2016; revised Dec. 26, 2016;
553
498 tained <160/110 mm Hg. Future in- May 2013. accepted Jan. 13, 2017. Q6
554
8. Florida Perinatal Collaborative. Hypertension The authors report no conflict of interest.
499 vestigations may want to focus on the Presented as an oral communication at the 37th 555
ideal posttherapy blood pressure goal in pregnancy HIP toolbox, 2016 (v2 2016).
500 Available at: health.usf.edu/publichealth/chiles/ annual meeting of the Society for Maternal-Fetal Medi- 556
and determine if an ideal threshold can cine, Las Vegas, NV, Jan. 23-28, 2017. Q2
501 fpqc/hip_toolbox. Accessed Dec. 24. 2016. 557
502 be identied that maximizes maternal 9. Shields LE, Kilpatrick SJ, Melsop K, Corresponding author: Laurence E. Shields, MD. 558
and neonatal outcomes. Peterson N. Timely assessment and treatment laurence.shields@dignityhealth.org

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