Statewide transfer policy impact for parturients with severe features of hypertensive disorders of pregnancy

To address increases in severe maternal morbidity (SMM) and mortality, systematic improvements in the care of high-risk parturients at facility and population levels have been advocated. Part of this effort involves levels of maternal care which account for perinatal regionalization and risk-appropriate maternal care for high-risk patients. In 7/2019, the Ohio Department of Health’s Maternity Licensure requirements established transfer of patients ≥37 weeks from Level 1 and ≥34 weeks from Level 2 to Level 3 or 4 perinatal centers for hypertensive disorders of peripartum with severe features (HDP-SF). Our analysis assessed changes following the statewide implementation. We retrospectively analyzed patients transferred from Level 1 and 2 centers to our Level 4 perinatal center from 1/2018 to 5/2021. Viable pregnancies >24 weeks with HDP-SF with evidence of liver injury (ALT/AST > 2x the upper limit of normal or ICD-10 code of liver failure) and renal injury (serum Cr >1.1 or ICD-10 code of renal failure) were included. Primary outcome measure included differences in intensive care unit (ICU) admission. Statistical significance was assessed by Chi-square and process control charts. Comparing the pre (n = 573) and post (n = 670) implementation of the statewide transfer policy, there was a significant increase in the rate of patients transferred with HDP-SF features based on liver (1.8% pre and 10.9% post, p< .01) and renal injury (4.4% pre and 8.6% post, p< .01) to our Level 4 facility. While statistically not significant, the rate of ICU transfer decreased 55% between pre- and post-implementation (2.0% pre and 0.9% post, p=.12) (Figure 1). The implementation of a statewide policy to transfer high-risk patients with HDP-SF from Level 1 and 2 hospitals to Level 4 perinatal centers resulted in identification of higher markers for SMM based on liver and/or renal injury. These statewide care arrangements may lead to earlier identification of SMM, resulting in more robust and appropriate services provided to these patients, ultimately leading to a reduction in ICU transfers.