Hypertension Bundle

Maternal Child Conference

Rachelle Heser, MSN, APRN, C-EFM

August 29, 2019

Objectives 1. Provide context around rising maternal mortality and morbidity rates within the United States.

2. Provide updates to definitions surrounding Hypertensive disorders of pregnancy

3. Increase awareness of the disease process and importance of early diagnosis and treatment

4. Describe the elements of the Hypertension Bundle and the benefit of routine drills for teams who are caring for women during and after delivery.

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Introduction-Maternal Mortality and Morbidity

• 700 women die each year as a result of pregnancy or pregnancy related complications

• United States has one of the highest Mortality/Morbidity rates in industrialized nations

• Non-Hispanic black women are 3- 4 x more likely to experience death than non-Hispanic white women.

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Data from 2015

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Maternal Mortality

This graph is courtesy of Dignity Health presentation on Driving Improvements in Hypertensive Disorders of Pregnancy.

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Maternal Mortality Review Committee (MMRC) Report from 9 states

States participating Themes identified

Colorado Patient/family factors

Delaware • Lack of knowledge on warning signs

Georgia • Lack of knowledge on how to seek care

Hawaii Provider

Illinois • Misdiagnosis

North Carolina • Ineffective treatment

Ohio Systems of care

South Carolina • Lack of coordination

Utah

Approximately 63% of pregnancy related deaths are preventable

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MMRC (continued)

• Years included for data ranged from 2008-2017

• Timing of death

• Pregnancy = 38%

• Within 42 days after delivery = 45%

• Between 42 days and 1 year after delivery = 18%

• When looking at Pre-eclampsia & Eclampsia chances increased after delivery

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MMRC –links with Preeclampsia and Eclampsia

Factor Contributing %

Provider factor 51.8%

• Knowledge & competenceDelayed diagnosis, treatment, Misdiagnosis, ineffective treatmentInappropriate level of care

20.7%

• Delayed or no referralFailure to seek consultation

13.8%

Patient factor 23.2%

Chronic conditions, including substance abuse and obesityLack of knowledge on warning signs and need to seek care

System of careLack of communication or coordination of care

17.9%

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MMRC Recommendations

193 recommendations from the committeeImprove trainingEnforce Policy and Procedures Adopt levels of maternal care/ensure appropriate level of care determination is madeImprove access to careImprove patient/provider communicationImprove patient management for maternal health conditionsImprove standards regarding assessment, diagnosis, treatment decisionsImprove polices related to patient management, communication and coordination between providers and language translationImprove policies regarding preventive initiatives including screening procedures, substance abuse prevention or treatment programs

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Maternal morbidity

Recognized SMM indicators during delivery hospitalizations

1. Acute Myocardial Infarction 10. Puerperal cerebrovascular disorders

2. Aneurysm 11. Pulmonary edema/acute heart failure

3. Acute renal failure 12. Severe anesthesia complications

4. Adult respiratory distress syndrome 13. Sepsis

5. Amniotic fluid embolism 14. Shock

6. Cardiac arrest/ventricular fibrillation 15. Sickle cell disease with crisis

7. Conversion of cardiac rhythm 16. Blood transfusion

8. Disseminated intravascular coagulation 17. Temporary tracheostomy

9. Heart failure 18. Ventiliation

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Call to Action-Safety Bundles

Council on Patient Safety in Women’s Health Care

AIM

ACOG

AWHONN

California Maternal Quality Care Collaborative (CMQCC)

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AIM projects

Alliance for Innovation on Maternal Health Program• Part of safe health care for every woman initiatives and

patient safety bundles

• National data driven maternal safety and quality initiative

• End goal is to eliminate preventable maternal mortality and severe morbidity across the United States

• Nebraska became an AIM state this year

• Iowa is looking at becoming one in the near future

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Hypertension Bundle

Items included in the Bundle from AIM/Council on Patient Safety

• Readiness• Have order sets & algorithms that address standards for early

warning signs, diagnostic criteria, monitoring and treatment for severe preeclampsia/eclampsia

• Unit education and drills with post-drill debriefs

• Timely triage & evaluation of pregnant and postpartum women with hypertension including ED and outpatient areas

• Rapid access to medications for severe hypertension/eclampsia

• System plan for escalation, appropriate consultation and transport as needed

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Hypertension Bundle

• Recognition and Prevention• Standard protocol for measurement and assessment of BP

• Standard response to maternal early warning signs, including listening to and investigating patient symptoms and assessment of labs

• Educating patients (prenatally and postpartum) on signs and symptoms of hypertension and preeclampsia

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Hypertension Bundle

• Response• Standard protocols with checklists and escalation policies for

management of • Severe hypertension• Eclampsia, seizure prophylaxis, and magnesium over-dosage• Postpartum presentation of severe hypertension/preeclampsia

• Minimum requirements for protocol• Notification of provider if systolic BP>/= 160 or diastolic >/=110 for two

measurements within 15 minutes • After the second elevated reading, treatment should be initiated ASAP

(preferably within 60 minutes of verification)• Includes onset and duration of magnesium sulfate therapy • Escalation measures for those unresponsive to standard treatment• Follow-up process within 7 – 14 days postpartum• Postpartum patient education for those with preeclampsia

• Support plan for patients, families and staff for ICU admissions and serious complications of severe hypertension

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Hypertension Bundle

• Reporting/Systems Learning• Create a culture of huddles for high risk patients and post-event

debriefs to identify successes and opportunities

• Multidisciplinary review of severe hypertension/eclampsia cases admitted to ICU for systems issues

• Monitor outcomes and process metrics

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Classifications of Hypertension

Hypertension in pregnancyGestational hypertension

Elevation of blood pressure after 20 weeks of gestation in the absence of proteinuria or systematic findings

Preeclampsia-eclampsia

With or without severe features

Chronic hypertension (of any cause)

Hypertension that predates pregnancy

Chronic hypertension with superimposed preeclampsia

Chronic Hypertension in association with preeclampsia

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Other Hypertensive disorders of pregnancy

HELLP-Hemolysis, Elevated liver enzymes, low platelet count.

• Severe forms of preeclampsia—shown to be associated with increased rates of maternal morbidity and mortality• LDH >/=600 IU/L

• AST and ALT elevated more than twice the upper limit of normal

• Platelets <100,000

• Generally occurs in 3rd trimester, 30% reported cases occur postpartum

• May also have an insidious or atypical onset (15% lack either hypertension or proteinuria)

• Main symptom displayed is right upper quadrant pain and generalized malaise. Also may complain of nausea and vomiting.

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Other Hypertensive disorders of pregnancy

Eclampsia

• Convulsive manifestation of hypertensive disorders of pregnancy

• New-onset tonic-clonic, focal or multifocal seizures in the absence of other causative conditions such as epilepsy, cerebral arterial ischemia and infarction, intracranial hemorrhage or drug use.

• Often preceded with premonitory signs of cerebral irritation such as severe and persistent occipital or frontal headaches, blurred vision, photophobia and altered mental status.

• May not display classic signs of preeclampsia before seizure episode

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BP criteria for Preeclampsia

Preeclampsia

• Blood pressure greater than or equal to 140 mm Hg systolic or greater than or equal to 90 mm Hg diastolic on 2 occasions at least 4 hours apart after 20 weeks gestation in a woman with previously normal BP’s.

Severe Preeclampsia (Preeclampsia with severe features)

• Blood pressure greater than or equal to 160 mmHg systolic or greater than or equal to 110 mm Hg diastolic. Confirm with a second reading within 15 minutes of the first to facilitate timely treatment with antihypertensive therapy.

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Preeclampsia criteria

Preeclampsia• Blood pressure greater than or equal to 140 mm Hg systolic or greater than or equal to

90 mm Hg diastolic on 2 occasions at least 4 hours apart after 20 weeks gestation in a woman with previously normal BP’s.

AND one of the following• Proteinuria

• >/= 300 mg per 24 hour urine collection OR• Protein/creatinine ratio greater than or equal to 0.3 mg/dl• Dipstick reading of +2 (used only if other quantitative methods not available)

• Platelet count less than 100,000/microliter• Serum creatinine concentrations greater than 1.1 mg/dL or a doubling of the serum

creatinine concentration in the absence of other renal disease• Elevated blood concentrations of liver transaminases to twice normal concentration • Pulmonary Edema• Cerebral or visual symptoms

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Preeclampsia

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Preeclampsia with severe features criteria

• Blood pressure greater than or equal to 160 mmHg systolic or greater than or equal to 110 mm Hg diastolic. Confirm with a second reading within 15 minutes of the first to facilitate timely treatment with antihypertensive therapy.

• Thrombocytopenia (platelet count less than 100,000/microliter)• Impaired liver function as indicated by abnormally elevated blood

concentration of liver enzymes, severe persistent right upper quadrant or epigastric pain unresponsive to medication and not part of an alternate diagnosis

• Progressive renal insufficiency (serum creatinine concentration greater then 1.1 mg/dL or doubling of serum creatinine concentration in absence of other renal disease)

• Pulmonary edema• New onset-cerebral or visual disturbances.

• Please note that a patient meets the criteria for preeclampsia with severe features due to her blood pressure.

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Preeclampsia with severe features

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Management of Hypertensive disorders of pregnancy

• The focus on hypertension treatment traditionally has been on prevention of eclampsia

• Lost sight on a major focus—control blood pressure to prevent stroke

• Delivery is the cure ---there are a certain percentage of women who will develop the symptoms within the first 6 weeks postpartum.

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Management of Hypertensive disorders of pregnancy

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Management of Hypertensive disorders of pregnancy

•Workup should include:• CBC, Platelet, Serum creatinine, LDH, AST, ALT and testing for

proteinuria

• Clinical maternal evaluation

• Fetal evaluation-ultrasound to include estimated fetal weight, AFI and antepartum testing (NST)

•Management will be depend on the evaluation and the gestational age

• Continued observation appropriate if preterm fetus, gestational HTN or preeclampsia without severe features.

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Medication Therapy

• Magnesium Sulfate—used as a treatment to prevent seizures not decrease BP.

• IV Labetalol and IV Hydralazine are considered first line medications for management of acute-onset severe hypertension in pregnant and postpartum women.

• PO Nifedipine is also considered a first line medication, especially if there is no IV access.

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Magnesium Sulfate

Usually administered IV with a bolus dose of 4-6 grams of 20% solution given over 20-30 minutes followed by a maintenance dose of 2-3 grams/hour

Can also be administered IM using a Z-track technique with a 3-inch 20 gauge needle

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Nifedipine sample order

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Labetalol

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Hydralazine

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Assessing Blood Pressure

• It is crucial to have a culture of safety to assist in improved outcomes for our perinatal population.

• Blood pressure measurement is one of the most important basic clinical assessments that we do, yet it is often one of the most inaccurately performed assessment, leading to delays in diagnosis and treatment. (Council on Patient Safety)

• Understanding the ramifications of blood pressure results is vital to successful treatment of our perinatal population-both during pregnancy and the first 6 weeks postpartum.

• Communication among the medical team improves early recognition and decreases the delay in initiation of treatment

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Assessing Blood Pressure

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Assessing Blood Pressure

Additional key points to consider:

1. Be consistent—use the same arm, same position and same cuff size

2. Evaluate BP trends vs. isolated values

3. If using automatic BP monitors, do not “auto-cycle”---be present to confirm appropriate BP technique criteria have been met

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Other elements to consider

• Early warning tools

• Safety huddles

• Safe reporting mechanisms

• Culture of safety

• Drills

• Debriefs

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Discharged-now what?

• Education on signs and symptoms

• Discharge teaching materials

• Follow-up phone calls with patients

• Support groups (Breast feeding)

• Early follow-up with provider• Within 3 – 7 days if medication was used to manage hypertension

• Within 7 – 14 days in no medication was used

• Readmissions

• Emergency room visit

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Discharge teaching-part of the discharge teaching for postpartum moms

https://www.awhonn.org/store/ListProducts.aspx?catid=&ftr=magnet

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It’s up to us

USA today

https://www.usatoday.com/in-depth/news/investigations/deadly-deliveries/2018/07/26/maternal-mortality-rates-preeclampsia-postpartum-hemorrhage-safety/546889002/

https://www.usatoday.com/deadly-deliveries/interactive/how-hospitals-are-failing-new-moms-in-graphics/

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https://www.preeclampsia.org/

https://safehealthcareforeverywoman.org/patient-safety-bundles/severe-hypertension-in-pregnancy/

https://www.cmqcc.org/

http://www.npqic.org/

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References

California Maternal Quality Care CollaborativeCouncil on Patient Safety in Women’s Health Care, Patient Safety Bundle-Hypertension. 2015Nebraska Perinatal Quality Improvement CollaborativeACOG- Committee Opinion. Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. Number 692; April 2017 and update (February 2019)ACOG Practice Bulletin-Gestational Hypertension and Preeclampsia. Vol. 133, No.1, January 2019ACOG Practice Bulletin-Chronic Hypertension in Pregnancy. Vol. 133, No.1, January 2019Bernstein,P. Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period. JOGNN 2017 vol. 46(5)Shields, L. Early standardized treatment of critical blood pressure elevations is associated with a reduction in eclampsia and severe maternal morbidity. AJOG. April 2017 Duley, L. Drugs for treatment of very high blood pressure during pregnancy (Review) Cochrane review. 2013Duro-Gomez, J. A trial of oral nifedipine and oral labetalol in preeclampsia hypertensive emergency treatment. Journal of Obstetrics and Gynaecology. May 2017Raheem, I. Oral nifedipine versus intravenous labetalol for acute blood pressure control in hypertensive emergencies of pregnancy: a randomized trial. BJOG. October 2011.Shekhar, S. Oral nifedipine or intravenous labetalol for hypertensive emergency in pregnancy: A randomized controlled trial. Obstetrics and Gynecology. November 2013.Vermillion, S. A randomized, double-blind trial of oral nifedipine and intravenous labetalol in hypertensive emergencies of pregnancy. AJOG. 1999.Report from Nine Maternal Mortality Review Commitees. Review to Action Maternal mortality review committee (MMRC), 2018.Callister, L. & Edwards, J. Sustainable development goals and the ongoing process of reducing maternal mortality. JOGNN, Vo. 46, No. 3, 2017