Prevention, Recognition and Management Strategies toward ...Use of Anti-hypertensive medications >160 systolic OR >110 diastolic is considered an hypertensive emergency in pregnancy

Prevention, Recognition and Management Strategies toward Decreasing Maternal Death

April 7 & 9, 2014

New York, New York

Syracuse, New York

New York State Perinatal Quality Collaborative Peter Cherouny, M.D.

NYSDOH Dept of Obstet, Gynecol and Reproductive Sciences University of Vermont

Dr. Cherouny has nothing to disclose

Hypertensive Disorders in Pregnancy Prevention, Recognition and Management Strategies

Review

Why is this important?

Reliable Design

Driver Diagram

Screening Tools

Identification of patients at increased risk of HDP

Management Strategies

Patient Education

Clinical Scenarios


Hypertensive Disorders in Pregnancy Why is this important?

Cause of Death N % of Total

Cardiac arrest/failure, NOS 39 22.9%

Hemorrhage 30 17.6%

Embolism 6 15.3%

PIH 21 12.4%

Infection 11 6.5%

Pulmonary Problems 9 5.3%

Unknown cause of death 8 4.7%

Cardiovascular problems 7 4.7%

Cancer 2 1.2%

Other cause of death 17 9.4%

Total Deaths 170 100%

http://www.nyc.gov/html/doh/downloads/pdf/ms/ms-report-online.pdf







All Causes

%

Embolism 24

PIH 24

Hemorrhage 15

Infection 15

New York State Department of Health

Cause of Death Number Percent

Embolism 28 17.4

Hemorrhage 27 16.8

PIH 23 14.3

Infection 23 14.3

Cancer 4 2.5

Anesthesia complications 3 1.9

Injury 3 1.9

Other cause of death 50 31.1

Total 161 100








Numbers

12-20%of pregnancies complicated with HDP

~1% will seize


Preventability of Hypertension related deaths

50-70% preventable

Majority of remainder have some clinical area identified for improvement

RCOG. Green top guideline No. 52. May 2009.


• Delays in presenting for care • Missed or misinterpreted clinical information • Delays in diagnosis

Over half of deaths related to HDP had vital sign evidence or other clinical triggers that were misidentified

• Delays in therapy

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Hypertensive Disorders in Pregnancy. Guideline Summary. New York State Department of Health, May, 2013.

Hypertensive Disorders in Pregnancy The 3 Delays Model

Preventability of Hypertension related deaths

What’s the problem? Preventable severe morbidity or mortality related to poor

clinical application of new knowledge regarding:

Dynamic nature of preeclampsia

Multi-systemic nature of preeclampsia

Possibility of post partum worsening or initial presentation of preeclampsia often outside of obstetric care

The over-commitment to previously taught rigid diagnostic “triad” criteria for preeclampsia


Hypertension

Systolic > 140mm Hg

Diastolic >90mm Hg

Severe Hypertension (hypertensive emergency)

Systolic >160mm Hg

Diastolic >110mm Hg


Considerations: Cuff size

Cuff bladder covers 75-100% of the arm circumference

Degree of stimulation Avoid tobacco/caffeine for 30

minutes

Undisturbed and at rest for 5 minutes

Posture Sitting with feet flat on floor,

back supported

Talking Silence during measurement

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http://en.hesperian.org/hhg/New_Where_There_Is_No_Doctor:Check_Health_Signs

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Diagnosis Blood Pressure Measurement

Additional Clinical Manifestations

Weeks at Presentation Lasting

Chronic (preexisting) hypertension

>140 mm Hg systolic or >90 mm Hg diastolic or both

None Before 20 weeks or prior to pregnancy

Beyond 12 weeks postpartum

Gestational Hypertension >140 mm Hg systolic or >90 mm Hg diastolic or both

None At or after 20 weeks without proteinuria or other features of preeclampsia

Preeclampsia >140 mm Hg systolic or >90 mm Hg diastolic or both without other severe features

new onset proteinuria (or other clinical manifestations)

At or after 20 weeks

Chronic hypertension with superimposed preeclampsia

>140 mm Hg systolic or >90 mm Hg diastolic or both, previously diagnosed

new or worsening proteinuria (or other clinical manifestations)

Before 20 weeks or prior to pregnancy

Chronic hypertension expected to continue beyond 12 weeks postpartum

Severe preeclampsia >160 mm Hg systolic or >110 mm Hg diastolic or both

Cerebral or visual disturbances, epigastric or RUQ pain, maternal end organ complications, abnormal labs or fetal morbidity

Eclampsia Preeclampsia (may have NOT been diagnosed)

New onset grand mal seizure in women with preeclampsia

Anytime during pregnancy or the postpartum period (six weeks)

PIH now called gestational hypertension (GHTN)

Severity of proteinuria eliminated in preeclampsia classification

Lack of association of degree of proteinuria with outcome

Presence of fetal IUGR eliminated from classification criteria

IUGR is managed similarly whether preeclampsia is present or not

The term “mild” preeclampsia is discouraged

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Hypertensive Disorders in Pregnancy Changes in Classification

Systemic dysfunction other than proteinuria Hepatic

greater than 2-fold elevation in transaminases epigastric or RUQ pain (without identifiable etiology)

Blood platelets < 100,00/mm3

Renal creatinine > 1.1 mg/dl or doubled

Respiratory pulmonary edema

CNS headaches visual changes seizures

These clinical findings define severe disease 16


Designing a system to do what we want it to do

Hypertensive Disease in Pregnancy Reliable Design

Prevent initial failure

intent and standardization function

Identify failure (defects) and mitigate

Redundancy function

Measure and then communicate learning from

defects Redesign function

Hypertensive Disease in Pregnancy Reliable Design Strategies

Contributes to building an infrastructure (who does

what, when, where, how and with what)

Support training and competency testing to sustain the process

Achieve front line articulation of key processes by staff

Allows the appropriate application of Evidence Based Medicine consistently

Feedback about errors and application of learning to design is possible


Must people rely on memory to complete any portion of the step (no reference, tool, etc.)?

Will a distraction or interruption during the step likely lead to failure of the step?

Are there >10 things a person must do at this step?

Is a new or untrained person much more likely to encounter error or failure with the step?


Reliance on memory

Distractions / interruptions

Fatigue

Sleep deprivation

Shift work

Lack of training and experience

Overload

Psychosocial factors

Decision aids and reminders built into the system

Desired action the default (based on scientific evidence)

Redundant processes utilized

Scheduling used in design development

Habits and patterns know and taken advantage of in the design

Standardization of process


Primary Drivers

Screening and Early Diagnosis of Maternal Hypertension

Acute Care Management of Hypertension, Maternal Pre-Eclampsia and Eclampsia

Patient Education on Signs and Symptoms of Hypertension, Preeclampsia and Eclampsia

Culture Change - Foster a culture of safety and improvement

Hypertensive Disease in Pregnancy Prevention, Recognition and Management Strategies

Primary Drivers (CMQCC)

Readiness

Recognition

Response

Reporting


Screening and Early Diagnosis of Maternal Hypertension Identify and adopt protocols for accurate assessment

of maternal blood pressure

Identify and adopt protocols for accurate assessment

of maternal risk for hypertensive disorders in pregnancy

Identify and adopt protocols for early warning signs

for hypertensive disorders in pregnancy


Acute Care Management Develop protocols for recognition and response to

deteriorating condition of maternity patients with hypertension, pre-eclampsia or eclampsia

Develop a Preeclampsia Rapid Response Box to

assist in the initiation of rapid delivery of medication to treat hypertensive crisis

Consider a rapid response team for targeted early

intervention


Patient Education

Provide patient education materials to increase patient awareness of signs and symptoms of prenatal and postpartum pre-eclampsia and the importance of appropriate prenatal and postpartum care

Counsel patients that hypertensive disorders during pregnancy may predict future cardiovascular risk



Schedule regular simulation drills

Identify clear lines of communication

Review cases of maternal preeclampsia and associated syndromes



Monitor and disseminate data

Add maternal hypertension treatment protocols to staff orientation

Include Emergency department staff in education and competency assessment


Historical focus on anti-seizure protocols

Magnesium sulfate

Shift focus to anti-hypertensive treatment

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Hypertensive Disorders in Pregnancy Management Strategies

Use of Anti-hypertensive medications

>160 systolic OR >110 diastolic is considered an hypertensive emergency in pregnancy This should be confirmed within 15 minutes and therapy

initiated in order to decrease blood pressure

Intravenous labetolol, hydralazine medications of choice

Standardized protocols should be used for treatment, provider notification, fetal and maternal surveillance

Emergent Therapy for Acute-Onset, Severe Hypertension With Preeclampsia or Eclampsia. ACOG Committee Opinion 514. December 2011.

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Use of Anti-seizure medications

Magnesium sulfate still first line therapy

Magnesium sulfate is recommended for antepartum patients with severe (complicated) preeclampsia

Magnesium sulfate is recommended for post partum patients with new onset hypertension with CNS findings (headache, visual changes, seizure)

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Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy: Executive Summary. Obstetrics & Gynecology. 122(5):1122-1131, November 2013.

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Yes Yes

No

No

Consultation &

evaluation for:

• Thyrotoxicosis

• Cardiomyopathy

• Pheochromocytoma

Treat

accordingly

• Stop vasoactive drugs

• Antihypertensive drugs

Response to treatment

No Yes

No further

evaluation

• Evaluate for arterial

stenosis & adrenal tumors

• Seek consultation

Persistent Postpartum Hypertension Algorithm*

Detailed history & physical examination – Presence of cerebral/gastrointestinal symptoms – Laboratory evaluation including proteinuria

• Preeclampsia

• Magnesium

sulfate

• Antihypertensives


No further

evaluation

Neurologic

consultation

Cerebral imaging

Hypertension only Hypertension plus

• Heart failure

• Palpitations, tachycardia

• Anxiety, shortness of

breath

Hypertension plus

• Proteinuria

• Cerebral symptoms

• Convulsions

Hypertension plus

Recurrent symptoms

Neurological deficits

Hypertension plus

• Nausea/vomiting

• Epigastric pain

• Elevated liver

enzymes

• Low platelets

• RCVS

• Stroke

HELLP Syndrome

• Magnesium

sulfate

• Antihypertensives

• Supportive care


No further

evaluation

Consultation &

evaluation for:

• Exacerbation of

lupus

• TTP/HUS

• APAS

• AFLP

• AFLP AFLP, acute fatty liver of pregnancy; APAS, antiphospholipid antibody syndrome; HELLP, hemolysis, elevated liver enzymes, and low platelet; HUS,

hemolytic uremic syndrome; RCVS, reversible cerebral vasoconstriction syndrome; TIP, thrombotic thrombocytopenic purpura.

*Adapted from Sibai. Postpartum hypertension-preeclampsia. Am J Obstet Gynecol 2012.

Changes in BP occur in the postpartum period, peak blood pressure occurs 3-5 days postpartum.

Postpartum women should not be discharged until BP controlled for >24 hours.

The provider and patient should have a plan to assess BP in the 3-5 day postpartum period

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Care depends on collaboration and communication among care team members Initiatives to standardize care

Informing providers of hypertension on initial evaluation

Informing anesthesia regarding the admission of a preeclamptic women

Discussion with family and team (obstetric, neonatal and anesthesia) when consideration for delivery <34 weeks gestation

Dissemination of evidence based clinical guidelines General management of preeclampsia

Severe hypertension management

Indications for seizure prophylaxis in preeclampsia

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Hypertensive Disorders in Pregnancy Summary

32 yo primiparous patient at 36+4 wks twin IUP, Vtx/Vtx

Presents to L&D with complaints of abdominal pain, contractions

BP 145/97 on admission

Proteinuria trace, CBC 42.1/14/13.2

Cervical examination; 2-3/80/-1, contractions irregular 2-5

Observed for one hour, abdominal pain worsened, pitocin started

Progressed into second stage; BP 145-162/95-111

Grand mal seizure during second stage

Fetal bradycardia, to OR for stat cesarean section

Spinal anesthesia, BP 92/45

Intraoperatively, patient is intubated as she loses consciousness

Intraoperative labs: Platelets 55 mm3, LFTs elevated, Cr 1.2

CT postop reveals small mid-pons intracranial bleed


Issues?


HYPERTENSIVE DISORDERS IN PREGNANCY – TRANSLATION TO ACTION

Marilyn Kacica, MD, MPH

NYSDOH Maternal Mortality Review 39

Roll-out Plan • Guidelines on the diagnosis, evaluation and

management of HDP presented and discussed during the 2013 Annual MMR meeting

• Guidelines posted on NYSDOH website and widely disseminated to hospitals across state

http://www.health.ny.gov/professionals/patients/women.htm

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Hypertensive Disorders in Pregnancy Guidance Document



Roll-out Plan

• Establish links to other professional websites

• Obtain advice from various professionals on point of use tools

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Hypertensive Disorders in Pregnancy Guidance Document

• NYSDOH received award from AMCHP as part of the Every Mother Initiative

• Award being used to focus on a project plan and translation of activities related to maternal morbidity / mortality

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Hypertensive Disorders in Pregnancy Every Mother Initiative

• Tailor Hypertensive Disorders of Pregnancy Guidelines into tools that facilitate clinical implementation of guidelines

• Provider training for continuing education (CME/CEU)

• Online training to take when convenient

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• Tools under development

• Outpatient*

• Measuring blood pressure poster

• Emergency Department

• Preeclampsia/eclampsia algorithm* (CMQCC)

• Preeclampsia early recognition tool*

• Patient education tool**

• Pregnant and postpartum

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* Working with CMQCC to adapt for NYS ** Working with Preeclampsia Foundation

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Questions?

Documents

Prevention, Recognition and Management Strategies toward ...Use of Anti-hypertensive medications >160 systolic OR >110 diastolic is considered an hypertensive emergency in pregnancy