Premier Hospital Engagement Network - PowerPoint Presentation

Premier Hospital Engagement Network OB GOALKEEPER COACHING CALL Hypertensive Disorders of Pregnancy September 3, 2014

2,400 Years of Preeclampsia History First described by Hippocrates around 400 BC Greek : eclampsia- “shine forth” or “lightening” T he uterus wandered the body capable of wreaking havoc upon the liver, stomach, spleen, lungs, nerves and head, ultimately leading to disease

Where are we today? 2

Preventing Maternal Death “Identify specific triggers for responding to changes in the mother’s vital signs and clinical condition and develop and use protocols and drills for responding to changes, such as hemorrhage and pre-eclampsia. Use the drills to train staff in the protocols, to refine local protocols, and to identify and fix systems problems that would prevent optimal care .” JC SE #44 ~ 2010

National Partnership for Maternal Safety Maternal Safety Bundles Obstetric Hemorrhage Hypertension in Pregnancy Prevention of VTE in Pregnancy Maternal Early Warning System CMQCC PREECLAMPSIA TOOLKIT PREECLAMPSIA CARE GUIDELINES

The 4 “R’s” Improve Readiness Make severe hypertensive protocol familiar and easy to implement (i.e. Order sets) Regular ongoing team education and drills Improve R ecognition Proper blood pressure recordingAppropriate Triage and AssessmentImplement systems to identify and treat women who may be developing critical illness, such as The Modified Early Obstetric Warning System (MEOWS) Improve Response Standardized severe hypertension and eclampsia management plans with checklists Management based on ACOG 2013 Hypertension Categories Comprehensive postpartum and post discharge planning Support program for patients, families and staff for all ICU admissionsTrained and activated teamsImprove ReportingEstablish a culture of “Huddles” for high risk patients and post-event debriefs Review all severe hypertension/ICU cases for systems issues Monitor outcomes and process metrics in Perinatal QI committeeMultidisciplinary monitoring and review *Modified from CMQCC and ACOG District II

Polling Questions Does your hospital or organization have a severe hypertensive disorder protocol that contains categories as outlined by the 2013 ACOG TF Guidelines? Yes No N/A Does your hospital or organization use early warning criteria to identify patients that need immediate bedside evaluation ? Yes No N/A Does your hospital or organization review all Severe Hypertension, Preeclampsia and Eclampsia cases for systems issues? Yes No N/A 6

Hypertensive Disorders of Pregnancy Assessment, Diagnosis, and Management Jeffrey S. Fouche, MSN, APRN, WHNP-BC, RNC-OB, C-EFM Perinatal Advanced Practice Nurse President Gwinnett Women’s Pavilion Perinatal Nurse Consulting of GA, LLC jfouche@gwinnettmedicalcenter.org perinatalnurse@icloud.com

Disclosures I have no relevant conflicts of interest to discloseNo commercial or other financial support was provided to develop this continuing nursing education activity No off-label use of medications or medical devices will be discussed To claim contact hours for this activity, participants must attend the activity in its entirety and complete an online evaluation

Objectives At the conclusion of this continuing nursing education activity, participants will be able to: Describe best practices for assessing patients with hypertensive disorders of pregnancy Define hypertension Differentiate between hypertensive disorders of pregnancy Develop and contribute to plans of care for patients with hypertensive disorders of pregnancy

Hypertensive Disorders of Pregnancy Incidence: 10% of pregnancies worldwide A leading cause of maternal and perinatal morbidity and mortality 50 – 100 serious non-fatal events for every preeclampsia-related death in the US Major contributor to prematurity Serious risk factor for future cardiovascular disease and metabolic disease in women

Cluster of Disorders

Measuring Blood Pressure Left lateral tilt will give false reading Why? How should we measure BP? Have the woman sit comfortably in a chair or in semi-Fowler’s position Let her rest for 5 minutes before taking a measurement Use an appropriately sized cuff Ensure that the middle of the BP cuff is at the level of the right atrium (mid-sternum) If the initial BP is elevated (≥140/90), recheck in 15 minutes

Hypertension defined SBP ≥ 140 mmHg or DBP ≥ 90 mmHg If either value is elevated—both do not need to be elevated to be considered hypertension Must be present on 2 measurements at least 4 hours apart

Additional Assessments

Gestational Hypertension Hypertension for the first time at ≥ 20 wks Absence of proteinuria and associated systemic signs and symptoms Progression to preeclampsia is more likely if diagnosed prior to 35 weeks Most common cause of hypertension in pregnancy Most often develops at ≥ 37 weeks

Severity of Gestational Hypertension Mild: Systolic, 140-159 mm Hg or Diastolic, 90-109 mm Hg Severe: Systolic ≥ 160 mm Hg or Diastolic ≥ 110 mm Hg

Hypertension Risks to Fetus The greatest risk of gestational hypertension is progression to preeclampsia. Mild gestational hypertension Outcomes comparable to no hypertension Severe gestational hypertension significant risk factor outcomes similar to women with preeclampsia with severe features

Management of Mild Gestational Hypertension

Indications for Delivery in Mild Gestational Hypertension EGA ≥37 weeks Onset of labor and/or SROM ≥34 weeks Usual obstetric indications unrelated to preeclampsia Based on fetal testing

Management of Severe Gestational Hypertension

Preeclampsia Proteinuria is defined as: ≥ 300 mg per 24-hour urine collection or Protein/creatinine ratio greater than or equal to 0.3 (both measured in mg/ dL ) Dipstick reading of 1+ (used only if other quantitative methods not available)

Preeclampsia

Subjective Symptoms of Preeclampsia

Risk Factors for Preeclampsia Nulliparity (or new male partner) Pre-existing disorders Chronic hypertension Renal disease Diabetes with vasculopathy Collagen vascular disease Thyroid disease Abnormal placental size or function Diabetes, multiple gestation, large placenta, APL syndrome Age (<19 or >40 years old) Previous pregnancy with preeclampsia Family history of preeclampsia Increased BMI African-American

Preeclampsia Disease unique to pregnancy Multisystem disorder- NOT just BP issue Induction of labor to prevent the progression of preeclampsia is responsible for 15% of preterm births. Early identification and intervention via delivery has changed little in 100 years Higher incidence and greater severity with multiple gestations and pre-existing diseases

Preeclampsia Pathophysiology

Placental Implantation Normal Kim, Y. J. (2013). Pathogenesis and promising non-invasive markers for preeclampsia. Obstetrics & Gynecology Science, 56 , 2-7. doi : 10.5468/OGS.2013.56.1.2 Articles published in Obstet Gynecol Sci are open-access, distributed under the terms of the Creative Commons Attribution Non-Commercial License Preeclampsia

Severe Features of Preeclampsia

Signs of Worsening Preeclampsia (Not Diagnostic)

Eclampsia

Eclampsia

Management of Eclampsia

Management of Eclampsia

HELLP Syndrome H Hemolysis of red blood cells E Elevated L Liver enzymes L Low P Platelets

HELLP Syndrome

Management of Preeclampsia Without Severe Features

Indications for Delivery in Preeclampsia Without Severe Features EGA ≥37 weeks Onset of labor and/or SROM ≥34 weeks Usual obstetric indications unrelated to preeclampsia Based on fetal testing

Management of Preeclampsia With Severe Features & HELLP

Indications for Delivery: Preeclampsia With Severe Features & HELLP Mode of delivery should be determined by EGA, fetal presentation, cervical status, and maternal and fetal conditions If unstable maternal or fetal conditions, delivery after stabilization, irrespective of EGA Pre-viable EGA  delivery after stabilization ≥34 weeks  delivery after stabilization <34 weeks  transfer to tertiary care center with perinatology consult

Indications for Delivery: Preeclampsia With Severe Features & HELLP

Indications for Delivery: Preeclampsia With Severe Features & HELLP

Magnesium Sulfate Used to prevent convulsions, NOT lower BP Must be infused via pump 1:1 care during loading dose Frequent vital signs during loading dose Magnesium levels not routinely needed unless serum creatinine > 1.2 or if UOP < 30mL/ hr Nursing assessments more reliable than magnesium levels Cannot be used in patients with myasthenia gravis Alert nursery for potential neonatal hypermagnesemia

Magnesium Toxicity Discontinue magnesium and notify MD if: Absent DTRs (use brachials if patient has epidural) Respirations < 12 per minute Pulse oximetry less than 95% (pregnant) or 92% (postpartum) despite 100% oxygen via face mask at 10-15 L/min If patient develops respiratory arrest, give 1 gram of 10% calcium gluconate IVP over 5 minutes Notify MD of shortness of breath, chest pain, or status changes such as onset of headache, blurred vision, epigastric pain, tachycardia, tachypnea, or adventitious breath sounds

Chronic Hypertension Presence of hypertension prior to the 20th completed week of gestation Higher incidence in older obese women and AAs 25% develop superimposed preeclampsia Oral antihypertensives are used to lower blood pressure (avoid ACEIs, ARBs) when needed Increased risk of IUFGR, PTD, IVH, LBW, & death 5-10% risk of abruptio placentae if uncontrolled Overall perinatal mortality is 3-4 times higher

Management of Chronic Hypertension

Indications for Delivery With Chronic Hypertension In the absence of superimposed preeclampsia, severe HTN, and maternal/fetal compromise, delivery before 38 weeks is not indicated If superimposed preeclampsia is present, then follow preeclampsia guidelines

Antihypertensive Therapy

Hypertensive Emergency Acute-onset, persistent (lasting 15 minutes or more)SBP ≥ 160 mm Hg OR DBP ≥ 110 mm Hg Loss of cerebral vasculature autoregulation Implement standing ordersHydralazine  labetalolLabetalol  hydralazine

Standing Order (Hydralazine)

Standing Order (Labetalol)

Follow-up BP Monitoring(once SBP and DBP below threshold)

HTN and Drug Use Chronic cocaine/amphetamine abuse may cause an exaggerated decrease in blood pressure. Hypotension may be difficult to treat due to altered vasopressor response and depleted endogenous catecholamine stores. Unexpected, severe hypotension may also occur after regional anesthesia or general anesthesia.

Hypertension in the Postpartum Period Preeclampsia may initially present in the postpartum period 40% of eclampsia is after delivery Postpartum women with new onset HTN with headache/blurred vision or with other s/s preeclampsia with severe HTN need magnesium sulfate to prevent seizures Persistent SBP ≥150 or DBP ≥100 (2 readings at least 4 hours apart): need antihypertensive medication

Hypertension in the Postpartum Period Continue to treat severe HTN (≥160/110) as hypertensive emergency With any hypertensive disorder, monitor BP for 72 hours after delivery and at the office/clinic at 7-10 days or sooner if symptoms If antihypertensives used in L&D or PP, early follow-up is indicated within 3-7 days Postpartum patients that present to ED should be transferred to L&D for evaluation

Staffing Considerations Antepartum patients: 2-3 women to 1 RN Intrapartum patients: 1:1 Postpartum patients: 2-3 women to 1 RN “Patient care assignments should take into account the level and expertise of the clinician or nurse assigned to care. Patients diagnosed with severe preeclampsia [sic] should be staffed with a 1:1 nurse to patient ratio, with the most experienced nurse available” (CMQCC, 2014)

Effects on On-going Health Lifelong risk of CV disease Up to 8-9 fold increase with severe preeclampsia prior to 34 weeks Therapeutic lifestyle changes (healthy weight, exercise, and avoidance of smoking) Annual evaluation of BP, lipids, BMI, and fasting blood glucose Future pregnancies are at risk, particularly if severe preeclampsia prior to 34 weeks or preeclampsia in > 1 pregnancy These women may be put on low-dose ASA in third trimester

References American College of Obstetricians and Gynecologists. (2011). Emergent therapy for acute-onset, severe hypertension with pre- eclampsia or eclampsia. Committee Opinion No. 514. Obstetrics & Gynecology, 118 , 1465-1468. American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy. (2013). Hypertension in Pregnancy . Washington, DC: Author. Druzin , M. L., Shields, L. E., Peterson, N. L., & Cape, V. (2013). Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care, developed under contract #11-10006 with the California Department of Public Health). Retrieved from California Maternal Quality Care Collaborative website: https://www.cmqcc.org/resources/2824 Roudsari , F. V., Ayati , S., Ayatollahi , H., & Shakeri , M. T. (2012). Protein/creatinine ratio on random urine samples for prediction of proteinuria in preeclampsia. Hypertension in Pregnancy, 31, 240-242. doi: 10.3109/10641955.2010.507838 Gabbe , S. G., Niebyl , J. R., Galan, H. L., Jauniaux , E. R. M., Landon, M. B., Simpson, J. L., & Driscoll, D. A. (2012). Obstetrics: Normal and Problem Pregnancies (6th ed.). Philadelphia, PA: Saunders . Magee , L. A., Helewa , M., Moutquin , J. M., & von Dadelszen , P. (2008). Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Journal of Obstetrics and Gynaecology Canada, 30 , S1-S48. Simpson, K. R., & Creehan , P. A. (2013). AWHONN's Perinatal Nursing (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Questions and Team Discussion 58

Upcoming Education SessionsSeptember 11th PFP/Quest/NCD/Maternal Affinity Group Webinar 3-4 p.m. EST: ““R” is for Readiness: Developing and improving your hospital's OB emergency simulation program”: Dr Jocelyn Davis and Dr. Rami Ahed , Summa Health System, CA Register now September 29th Perinatal Core Measures 11:00 – 12:30 EST: TN & NCD/Maternal Affinity Group, “Review of 2015 Proposed Perinatal Core Measures” by Celeste Milton, The Joint Commission Space is limited. Register at : https://www4.gotomeeting.com/register/266536319 October 1 st Premier OB Coaching Call & NCD/Maternal Affinity Group: 1-2:30 pm EST: “Implementing Quantification of Blood Loss”: Amy Scott and Jennifer McNulty, Miller Children's Hospital, CA. (Link coming soon)November 11th Premier Coaching Call & NCD/Maternal Affinity Group: 1-2:30 p.m. EST: “New” Maternal Bundles by Dr Elliott Main, Director; California Maternal Quality Care Collaborative. (Link coming soon) 59

Contact Information Deb Kilday: deborah_kilday@premierinc.com Jeffrey S. Fouche: JFouche@gwinnettmedicalcenter.org 60

References D’Alton , ME. (2014). National Partnership for Maternal Safety. Obstet Gynecol, 123, 973-977 . Mackintosh , N. (2014). Value of a modified early obstetric warning system (MEOWS) in managing maternal complications in the peripartum period: an ethnographic study BMJ Qual Saf, 23, 26-34 .Main EK. (2013). Maternal Mortality: Time for National Action. Obstet Gynecol, 122, 735-736. 61