pqcnc 2014 annual meeting arthur ollendorff
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8/13/2019 PQCNC 2014 Annual Meeting Arthur Ollendorff
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Conservative
Management of
Preeclampsia
(C-MOP)
PQCNC Annual Meeting
January 7, 2014
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Arthur Ollendorff, MDMAHEC OB/GYN Specialists
Asheville, NC
Clinical Professor of OB/GYN
University of North Carolina SOM
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Outline for Afternoon
2:00-2:45 Elliott Mane
Quality Improvement in Preeclampsia
2:50-3:10 Kathy & Clark Ellis
The Family’s Perspective
3:10-3:35 Arthur Ollendorff
Classification of Hypertension in Pregnancy
3:45-3:55 Break3:55-4:40 Arthur Ollendorff
CMOP Action Plan Review
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ACOG Publication-October 2013
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From the ACOG document
“The information in Hypertension in Pregnancy
should not be viewed as a body of rigid rules. The
guidelines are general and intended to be adapted
to many different situations, taking into accountthe needs and resources particular to the locality,
the institution, or the type of practice. Variations
and innovations that improve the quality of patient
care are to be encouraged rather than restricted.The purpose of these guidelines will be well
served if they provide a firm basis on which local
norms may be built.”
Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
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My Favorite Definition of EBM
Evidence-Based Medicine is critical
appraisal of the literature applied through
the clinician’s experience and judgment
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The Modified Evidence Pyramid
Quality of Evidence
High
Low Individual
Patient
Large Populations
Applicability
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“Old” CCNC Pathway Classification of
Hypertensive Disorders of Pregnancy
• Gestational Hypertension
• Mild Preeclampsia
• Severe Gestational Hypertension• Severe Preeclampsia
• Chronic Hypertension with Superimposed
Preeclampsia
CCNC Pregnancy Medical Home Program Care Pathway:Management of women with hypertensive disorders of pregnancy. August 2012.
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ACOG Classification -
Hypertensive In Pregnancy
Chronic hypertension
Gestational hypertension
Preeclampsia/Eclampsia without severe features
with severe features
Chronic hypertension withsuperimposed preeclampsia
Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
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What Has Changed
Terminology
Preeclampsia without severe features
• Formerly called mild preeclampsia Preeclampsia with severe features
• Formerly called severe preeclampsia
Blood pressure criteria are 4 hoursapart rather than 6 hours apart
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Severe Features of Preeclampsia
Systolic blood pressure of 160 mm Hg or higher, or
diastolic blood pressure of 110 mm Hg or higher on two
occasions at least 4 hours apart while the patient is on
bed rest
Thrombocytopenia (platelet count less than
100,000/microliter)
Impaired liver function as indicated by abnormally
elevated blood concentrations of liver enzymes (to twice
normal concentration), severe persistent right upper
quadrant or epigastric pain unresponsive to medication
and not accounted for by alternative diagnoses, or both
Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
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Severe Features of Preeclampsia
Progressive renal insufficiency (serum
creatinine concentration greater than 1.1 mg/dL
or a doubling of the serum creatinine
concentration in the absence of other renaldisease)
Pulmonary edema
New-onset cerebral or visual disturbances
Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
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What Else Has Changed
Preeclampsia can exist without
proteinuria
Preeclampsia with severe featurescan be diagnosed with any severe
feature
• Severe Gestational Hypertension no
longer exists
Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
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Changing Providers’
Behavior Is Like……
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A Stepwise Approach
1. Was elevated blood pressure present
before 20 weeks gestational age?
Yes – Classification can only be• Chronic hypertension
• Chronic hypertension with
superimposed preeclampsia
No – Classification can be• Preeclampsia
• Gestational hypertension
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A Stepwise Approach
2. Patient with new blood pressure
elevation after 20 weeks gestational
age. Are there severe featurespresent
Yes – Classify as Preeclampsia with
severe features
No – Evaluate for proteinuria
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Severe Features of
Preeclampsia
Blood Pressure > 160/110
Platelets < 100,000
Impaired liver function based on LFTor symptoms
Renal insufficiency
Pulmonary edema Cerebral or visual disturbances
Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
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A Stepwise Approach
3. Patient with new onset elevated
blood pressure and no severe
features. Perform 24 hour urine forprotein.
< 300 mg - classify as gestational
hypertension
≥ 300 mg - classify as preeclampsia
without severe features
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Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
8/13/2019 PQCNC 2014 Annual Meeting Arthur Ollendorff
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ACOG’s Guidance on
Clinical Conundrums
Subjective symptoms that define
severe features
Diagnosing chronic hypertension withsuperimposed preeclampsia
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Subjective Symptoms
Right upper quadrant/epigastric pain
Severe and persistent
Unresponsive to medication Not accounted for by alternative
diagnoses
Cerebral/visual disturbances Document inconsistently mentions
new-onset and persistent
Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
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Chronic hypertension with
superimposed preeclampsia
Superimposed preeclampsia should
be considered when there is
a sudden increase in BP that waspreviously well controlled
sudden, substantial and sustained
increase in proteinuria
development of severe features
Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
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Superimposed Preeclampsia
“Clinicians should recognize that there
is often ambiguity in the diagnosis of
superimposed preeclampsia and that
the clinical spectrum of disease isbroad”
“Increased surveillance but not
intervention (e.g. delivery) iswarranted even if the diagnosis is
suspected and not definitive”
Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
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When In Doubt Use This
Resource
Hypertension In Pregnancy (2013). ACOG Hypertension In PregnancyTaskforce.
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C-MOP Participating Sites
★
★
★
★
★ ★ ★
★
★
★
Caromont
Cleveland Regional
CMC-Main
CMC-Northeast
Columbus
Duke
Forsyth
Granville
McDowell
Mission
New Hanover
Novant-Huntersville
Rex
Transylvania
UNC
Vidant
Womack
★
★
★
★
★ ★ ★
January 2, 2014
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C-MOP Action Plan
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C-MOP Action Plan
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C-MOP Action Plan
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C-MOP Action Plan