Prevention, Recognition and Management Strategies toward ...Use of Anti-hypertensive medications...
Transcript of Prevention, Recognition and Management Strategies toward ...Use of Anti-hypertensive medications...
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 Prevention, Recognition and Management Strategies
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
http://www.nyc.gov/html/doh/downloads/pdf/ms/ms-report-online.pdf
Numbers
12-20%of pregnancies complicated with HDP
~1% will seize
Hypertensive Disorders in Pregnancy Prevention, Recognition and Management Strategies
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.
Hypertensive Disorders in Pregnancy Prevention, Recognition and Management Strategies
• 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
Hypertensive Disorders in Pregnancy Prevention, Recognition and Management Strategies
Hypertension
Systolic > 140mm Hg
Diastolic >90mm Hg
Severe Hypertension (hypertensive emergency)
Systolic >160mm Hg
Diastolic >110mm Hg
Hypertensive Disorders in Pregnancy Prevention, Recognition and Management Strategies
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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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
Hypertensive Disorders in Pregnancy Prevention, Recognition and Management Strategies
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
Hypertensive Disease in Pregnancy Reliable Design Strategies
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?
Hypertensive Disease in Pregnancy Reliable Design Strategies
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
Hypertensive Disease in Pregnancy Reliable Design Strategies
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
Hypertensive Disease in Pregnancy Prevention, Recognition and Management Strategies
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
Hypertensive Disease in Pregnancy Prevention, Recognition and Management Strategies
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
Hypertensive Disease in Pregnancy Prevention, Recognition and Management Strategies
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
Hypertensive Disease in Pregnancy Prevention, Recognition and Management Strategies
Culture Change - Foster a culture of safety and improvement
Schedule regular simulation drills
Identify clear lines of communication
Review cases of maternal preeclampsia and associated syndromes
Hypertensive Disease in Pregnancy Prevention, Recognition and Management Strategies
Culture Change - Foster a culture of safety and improvement
Monitor and disseminate data
Add maternal hypertension treatment protocols to staff orientation
Include Emergency department staff in education and competency assessment
Hypertensive Disease in Pregnancy Prevention, Recognition and Management Strategies
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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Hypertensive Disorders in Pregnancy Management Strategies
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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Hypertensive Disorders in Pregnancy Management Strategies
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
Response to treatment
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
Response to treatment
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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Hypertensive Disorders in Pregnancy Management Strategies
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
Hypertensive Disease in Pregnancy Prevention, Recognition and Management Strategies
Issues?
Hypertensive Disease in Pregnancy Prevention, Recognition and Management Strategies
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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Hypertensive Disorders in Pregnancy Every Mother Initiative
• 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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Hypertensive Disorders in Pregnancy Every Mother Initiative
* Working with CMQCC to adapt for NYS ** Working with Preeclampsia Foundation
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Questions?