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Creating a Team for Maternal Safety The Case of Preeclampsia

Elliott K. Main, MD
Medical Director, CMQCC Clinical Professor, Obstetrics and Gynecology University of California, San Francisco, and Stanford University, Medical School

Objectives:

Describe national initiatives to reduce perinatal and maternal mortality and severe morbidity Describe the California Maternal Quality Care Collaborative structure and function Describe QI approaches to Preeclampsia used by other organizations

Presenter Disclosure(s):

No conflicts to disclose Supported with grants from the California HealthCare Foundation and the CDC
: Transforming Maternity Care
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Maternal Mortality Ratios in Selected Countries over the Past 30 Years


25

Maternal Mortality Ratio

20

1980 2000

1990 2008

(per 100,000 births)

15

10

: Transforming Maternity Care Hogan et al, Lancet 2010; 375: 1609 23

Literature review and over 100 in-depth interviews and focus groups Focus on disparity (esp African American women) and on variation among the states Scathing indictment of US healthcare system for maternity care

2010

: Transforming Maternity Care

: Transforming Maternity Care

Maternal Mortality Rate, California Residents; 1970-2006


ICD-8
Maternal Deaths per 100,000 Live Births

ICD-9

ICD-10

HP 2010 Objective 4.3 Deaths per 100,000 Live Births

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1970-2006. Maternal mortality for California (deaths 42 days postpartum) were calculated using the ICD -8 cause of death classification for 1970-1978, ICD-9 classification for 1979-1998 and ICD-10 for 1999 to 2006. Produced by California Department of Public Health; Maternal, Child and Adolescent Health Program, March 2010.

Maternal Mortality Rate, California and United States; 1999-2010


18.0
Maternal Deaths per 100,000 Live Births
16.9 14.6 13.1 10.9 9.9 9.8 7.7 United States Rate 9.9 9.7 8.9 10.0 12.1 11.8 11.7 13.3 11.1 9.2 California Rate 15.1 12.7 14.0 11.6 15.5

16.6

16.8

16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0


1999 2000 2001 2002

HP 2020 Objective 11.4 Deaths per 100,000 Live Births


2003 2004 2005 2006 2007 2008 2009 2010

Year
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) for 1999-2010. United States data and HP2020 Objective were calculated using the same methods. U.S. maternal mortality rates are published by the National Center for Health Statistics (NCHS) through 2007 only. Rates for 2008-2010 were calculated using NCHS Final Birth Data (denominator) and CDC Wonder Online Database for maternal deaths (numerator). Accessed at http://wonder.cdc.gov/ucd-icd10.html on Apr 17, 2013 8:00:39 PM. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, April, 2013.

Maternal Mortality Rates by Race/Ethnicity, California Residents; 1999-2006

Maternal Deaths per 100,000 Live Births

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2006. Maternal mortality for California (deaths < 42 days postpartum) calculated beginning 1999 using ICD-10 cause of death codes A34, O00-O95, O98-O99. Maternal single race code used 1990-1999; multirace code used beginning 2000. Produced by California Department of Public Health; Maternal, Child and Adolescent Health Program, March 2010.

Maternal Mortality and Severe Morbidity


Approximate distributions, compiled from multiple studies

Mortality

Cause
VTE and AFE Infection Hemorrhage Preeclampsia Cardiac Disease

(1-2 per 10,000)

ICU Admit Severe Morbid (1-2 per (1-2 per


1,000) 100)

15% 10% 15% 15% 25%

5% 5% 30% 30% 20%

2% 5% 45% 30% 10%

Maternal Mortality and Severe Morbidity


Approximate distributions, compiled from multiple studies

Mortality

Cause
VTE and AFE Infection Hemorrhage Preeclampsia Cardiac Disease

(1-2 per 10,000)

ICU Admit Severe Morbid (1-2 per (1-2 per


1,000) 100)

15% 10% 15% 15% 25%

5% 5% 30% 30% 20%

2% 5% 45% 30% 10%

Maternal Mortality and Severe Morbidity


Approximate distributions, compiled from multiple studies

Mortality

Cause
VTE and AFE Infection Hemorrhage Preeclampsia Cardiac Disease

(1-2 per 10,000)

ICU Admit Severe Morbid (1-2 per (1-2 per


1,000) 100)

15% 10% 15% 15% 25%

5% 5% 30% 30% 20%

2% 5% 45% 30% 10%

Maternal Mortality and Severe Morbidity


Approximate distributions, compiled from multiple studies

Mortality

Cause
VTE and AFE Infection Hemorrhage Preeclampsia Cardiac Disease

(1-2 per 10,000)

ICU Admit Severe Morbid (1-2 per (1-2 per


1,000) 100)

15% 10% 15% 15% 25%

5% 5% 30% 30% 20%

2% 5% 45% 30% 10%

Our 3 Overlapping but Non-identical Frameworks

Public Health

Quality

Safety

Different professional groups with different trainings and world views Different agendas and priorities Different frames and models
Far and away the greatest impact occurs when we work together!!
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= Outcomes

: Transforming Maternity Care

CoIIN to Reduce Infant Mortality


Maternal Child Health-Branch

Initially in Regions IV and VI now national

5 Priorities to Reduce Infant Mortality and Improve Birth Outcomes

Reduce elective delivery at less than 39 weeks of pregnancy by 33%; Expand access to inter-conception care (between pregnancies) through Medicaid; change policy is 5-8 states; Reduce smoking among pregnant women by 3%; Increase infant safe sleep practices by 5%; Improve perinatal regionalization-- increase the number of mothers delivering at appropriate facilities by 20%
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Society for Maternal-Fetal Medicine (SMFM)

Maternal Child Health Branch (MCH-B) Division of Reproductive Health

National Maternal Health Initiative: Strategies to Improve Maternal Health And Safety
May 5th 2013 New Orleans, LA
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Society for Maternal-Fetal Medicine (SMFM)

Maternal Child Health Branch (MCH-B) Division of Reproductive Health

What every birthing facility in the US should have

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3 Maternal Safety Bundles SMFM/ACOG/AWHONN workgroups

Obstetric Hemorrhage Hypertension in Pregnancy Prevention of VTE in Pregnancy


--Strong support that every hospital needs to have a protocol and bundle, not the protocol --Each safety bundle is designed with key components / tools with example materials
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ACOG/CDC workgroups on Maternal Supporting Bundles


Maternity Care QI: Importance of Process David Lagrew Common issues in introducing change (safety bundles) Maternal Early Warning Criteria - Jill Mhyre Criteria to identify women who require immediate bedside assessment by an MD Severe Maternal Morbidity Facility Review Sarah Kilpatrick, Every case should be reviewed by a multidisciplinary team with a goal of systems improvement Staff, Family and Patient Support Cynthia Chazotte Support resources for all those involved in a severe maternal morbidity or mortality
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Council for Patient Safety in Womens Health ACOG/AWHONN/ACNM/SMFM/AAFP Washington DC, July 29, 2013 Formal Support and Endorsement of National Partnership for Maternal Safety Will coordinate dissemination and Implementation of: Three bundles, three years among the following agencies:
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Creating the Collaborative for Change


Federal (MCH-B, CDC, CMS/CMMI) Obstetricians (ACOG/SMFM/ ACOOG) Family Practice (AAFP) OB Anesthesia (SOAP) Blood Banks (AABC) Hospitals (AHA, VHA) Perinatal Quality Collaboratives (many) Nurses (AWHONN) State (AMCHP, ASTHO, MCH)

Midwives (ACNM)

Maternal Safety

Nurse Practitioners (NPWH)

Birthing Centers (AABC)


Safety, Credentials (TJC)
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Direct Providers

Editorial: 122(4):735-736, October 2013

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CMMI: Center for Medicare & Medicaid Innovation

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Hospital Engagement Networks (HENs)


Over 3,700 participating hospitals focused on making hospital care safer, more reliable, and less costly 10 core patient safety areas, one is reduction of obstetrical adverse events with an initial primary focus: Early Elective Deliveries North Carolina HENs:
North Carolina Hospital Association (NCHA) Carolinas Health Care System
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Hospital Engagement Networks (HENs): 2014


Additional focuses for OB adverse Events:
OB Hemorrhage Preeclampsia

Safety bundles Measures

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The Joint Commission: Hospital regulator and Champion of safety

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The Joint Commission Sentinel Alert: Improvement Opportunities


Better recognition and treatment of hemorrhage especially following Cesarean birth Better control of BP in hypertensive women Better diagnosis and treatment pulmonary edema in women with preeclampsia Closer attention to vital signs, use of triggers Greater use of pneumatic compression devices and low molecular weight heparin in high risk patients undergoing a Cesarean birth Education of ED staff to complications of pregnancy and the postpartum period
The Joint Commission Sentinel Alert #44, January 26, 2010
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The Joint Commission Sentinel Event: New Criteria for OB Beginning Jan 2014 Intended not be punitive but educational Identify cases to review carefully for systems improvement opportunities For Obstetrics, they define severe maternal morbidity: All cases with 4 units of blood products All cases admitted to an ICU These cases would have a RCA. ACOG has developed a package to aid reviews
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California: Scale of Maternity Services


Population (2012): 38 million >500,000 annual births (1/8 of all US births) 260+ hospitals with maternity services 125 NICUs (levels 2 and 3) Large geographic diversity: urban and rural Extensive racial/ethnic diversity
29%

of births are non-Hispanic white Language other than English spoken at home: 43.5%

7 medical schools,10+ hospital systems, 11 MCH Perinatal Regions, 3 Hospital associations


: Transforming Maternity Care
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CMQCC and CPQCC


Mission: Data-driven QI for mothers and newborns
California Perinatal Quality Care Collaborative (CPQCC)
Established 1996 >95% of all Neonatal Intensive Care Units in California Secure data centerpioneer for data driven QI Model of working with state agencies to provide data of value

California Maternal Quality Care Collaborative (CMQCC)


Established 2006, sister to CPQCC California Maternal Mortality Review Committee (Title V, MCAH) QI toolkits: Elective Delivery <39wks, Hemorrhage, Preeclampsia, Large-scale QI Collaboratives: Hemorrhage, Preeclampsia Statewide Maternal Data Center (CDC and CHCF supported)

: Transforming Maternity Care

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CMQCC Key Partner/Stakeholders


State Agencies: MCAH, Dept Public Health OSHPD Healthcare Information Division Office of Vital Records (OVR) Regional Perinatal Programs of California (RPPC) DHCS, Medi-Cal Public Groups California Hospital Accountability and Reporting Taskforce (CHART) Kaiser Family Foundation March of Dimes (MOD) Pacific Business Group on Health Professional groups American College of Obstetrics and Gynecology (ACOG--District IX) Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN--California Section) American College of Nurse Midwives (ACNM-California Section), American Academy of Family Physicians (AAFP--CAFP) Key Medical and Nursing Leaders University and Hospital Systems Kaisers, Sutter, Sharp, CHW, Scripps, Public hospitals, : Transforming Maternity Care

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CPQCC/ Neonatal and Perinatal Toolkits and Collaboratives


Toolkits:
Antenatal Corticosteroid Therapy Improving Initial Lung Function: Early CPAP, Surfactant Postnatal Steroid Administration Nutritional Support of the Very Low Birth Weight Infant Prevention of Perinatal Group B Streptococcus Disease Toolkit Severe Hyperbilirubinemia Prevention (SHP) Perinatal HIV Prevention Delivery Room Management of the VLBW Infant Neonatal Hospital Acquired Infection Prevention Care and Management of the Late Preterm Infant www.cpqcc.org

Current Collaboratives:
Prevention of Central line infections Reduction of VLBW LOS
: Transforming Maternity Care
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CMQCC Toolkits and Collaboratives

Maternal Mortality and Morbidity

National Quality Measures

Hemorrhage Preeclampsia CV Disease* DVT Prevention*

Early Elective Delivery Antenatal Steroids First Birth Cesarean Delivery*

*Currently under development


: Transforming Maternity Care
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Networking for Effective Change


Doctors Midwives Nurses

Offices/C linics

Hospitals
1) Engage each from the beginning 2) Evaluate the project from each viewpoint 3) Create a work plan for each stakeholder 33

Public Payers/M edicaid

MCH/Sta te

: Transforming Maternity Care

Everyones nightmare

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QI Topic 1: OB Hemorrhage
Statewide CMQCC OB Hemorrhage QI Taskforce
Large, multi-disciplinary, overlap with Maternal Mortality Review Funded by CDPH-MCAH, completed in 2009

California OB Hemorrhage QI Toolkit


Published in 2010, currently under revision Best practices, guidelines, hemorrhage cart and med kit, blood bank integration, and drill scenarios www.cmqcc.org (in top 5 on Google for OB hemorrhage)

CMQCC OB Hemorrhage QI Collaboratives


2010: 30 hospitals (~100,000 births) 2011: 24 hospitals (~85,000 births) 2011-on: multiple hospital systems, Los Angeles County

Open Access Toolkit of Best Practices

Guidelines, protocols, checklists, sample policies, support materials Series of Best Practice discussions on all OB hemorrhage topics, from Accreta to Jehovahs Witness to Uterotonic agents www.CMQCC.org
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: Transforming Maternity Care

CMQCC California Hemorrhage Guidelines

These are open access tools being utilized in many : Transforming Maternity Carestates

CMQCC OB Hemorrhage Care Guidelines

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STAGE 1: OB Hemorrhage
Cumulative Blood Loss >500ml vaginal birth or >1000ml C/S -ORVital signs >15% change or HR 110, BP 85/45, O2 sat <95% -ORIncreased bleeding during recovery or postpartum
MOBILIZE ACT THINK

Primary nurse, Physician or Midwife to: Activate OB Hemorrhage Protocol and Checklist Primary nurse to: Notify obstetrician (in-house and attending) Notify charge nurse Notify anesthesiologist

Primary nurse: Establish IV access if not present, at least 18 gauge Increase IV fluids rates (Lactated Ringers preferred) and increase Oxytocin rate (500 mL/hour of 10-40 units/1000mL solution); Titrate Oxytocin infusion rate to uterine tone Continue vigorous fundal massage Administer Methergine 0.2 mg IM per protocol (if not hypertensive); give once, if no response, move to alternate agent; if good response, may give additional doses q 2 hr Vital Signs, including O2 sat & level of consciousness (LOC) q 5 minutes Weigh materials, calculate and record cumulative blood loss q 5-15 minutes Administer oxygen to maintain O2 sats at >95% Empty bladder: straight cath or place Foley with urimeter Type and Crossmatch for 2 units Red Blood Cells STAT (if not already done) Keep patient warm Physician or midwife: Rule out retained Products of Conception, laceration, hematoma Surgeon (if cesarean birth and still open) Inspect for uncontrolled bleeding at all levels, esp. broad ligament, posterior uterus, and retained placenta

Consider potential etiology: Uterine atony Trauma/Laceration Retained placenta Amniotic Fluid Embolism Uterine Inversion Coagulopathy Placenta Accreta Uterine Rupture

Once stabilized: Modified Postpartum management with increased surveillance

If: Continued bleeding or Continued Vital Sign instability, and <1500 mL cumulative blood loss proceed to STAGE 2

UTEROTONIC AGENTS for POSTPARTUM HEMORRHAGE


Drug Pitocin (Oxytocin)
10 units/ml

Dose
10-40 units per 1000 ml, rate titrated to uterine tone

Route
IV infusion

Frequency
Continuous

Side Effects
Usually none Nausea, vomiting, hyponatremia (water intoxication) with prolonged IV admin. BP and HR with high doses, esp IV push Nausea, vomiting Severe hypertension, esp. with rapid administration or in patients with HTN or PIH

Contraindications
Hypersensitivity to drug Hypertension, PIH, Heart disease Hypersensitivity to drug Caution if multiple doses of ephedrine have been used, may exaggerate hypertensive response w/possible cerebral hemorrhage Caution in women with hepatic disease, asthma, hypertension, active cardiac or pulmonary disease Hypersensitivity to drug Rare Known allergy to prostaglandin Hypersensitivity to drug

Storage
Room temp

Methergine (Methylergonivine)
0.2mg/ml

0.2 mg

IM (not given IV)

-Q 2-4 hours -If no response after first dose, it is unlikely that additional doses will be of benefit -Q 15-90 min -Not to exceed 8 doses/24 hrs -If no response after 3 doses, it is unlikely that additional doses will be of benefit. One time

Refrigerate Protect from light

Hemabate (15-methyl PG F2a)


250mcg/ml

250 mcg

IM or intramyometrial (not given IV)

Nausea, vomiting, Diarrhea Fever (transient), Headache Chills, shivering Hypertension Bronchospasm Nausea, vomiting, diarrhea Shivering, Fever (transient) Headache

Refrigerate

Cytotec (Misoprostol)
100 or 200mcg tablets

800-1000mcg

Per rectum (PR)

Room temp

California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details

Obstetric Hemorrhage Safety Bundle Draft ACOG/AWHONN/SMFM


Risk Assessment:
Assessment of hemorrhage risk antepartum, on admission and late labor

Prevention:
Active Management of 3rd Stage: oxytocin after delivery

Readiness:
Partnership with Transfusion Service (aka Blood Bank) for un-crossmatched and
massive transfusion protocols and timely availability Other resources (including surgery, MFM, higher level facility referrals, social work) Hemorrhage Cart / with Procedural Instructions (balloons, compression stitches) Education (RN, OB, Anesthesia, and Emergency Room physicians) including didactic training and drills

Recognition/Response:
Endorse a unit-standard stage-based hemorrhage protocol with a task checklist Systematic and semi-quantitative approach to CUMMULATIVE blood loss

Unit Learning/Systems Improvement:


Short Debriefs following all hemorrhage cases, and Mini Root Cause Analyses after severe events utilizing standardized methods/reporting forms
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Obstetric Hemorrhage: Proposed Measures


(HENs and Quality Collaboratives)

Process: Risk assessment done on every patient? (sample) Outcome 1: Total number of units of blood products per 100 mothers giving birth Outcome 2: Number mothers giving birth who received 4 units of blood products per 1,000 births (massive transfusion)

: Transforming Maternity Care

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QI Topic 2: Preeclampsia
Quality Improvement Opportunity Examples from PAMR:
Missed triggers: high BP (systolic and diastolic), pain, altered mental status, O2 saturation, fetal distress Underutilization of Magnesium SO4 and anti-hypertensive medications Difficulties getting physician to the bedside, and obtaining consultations Location of care issues involving Postpartum, ED and PACU

Key Supports:
The Joint Commission Sentinel Alert #44: Preventing Maternal Death (2010) ACOG Committee Opinion #514: Emergent Therapy for AcuteOnset, Severe Hypertension with Preeclampsia or Eclampsia (Dec 2011)

Executive Summary: Hypertension in pregnancy American College of Obstetricians and Gynecologists,


Obstet Gynecol 2013;122:1122-31
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Diagnosis Criteria for Preeclampsia

Executive Summary: Hypertension in Pregnancy, American College of Obstetricians and Gynecologist, Obstet Gynecol 2013;122:1122-31. Copyright permission received.

Diagnosis of Severe Preeclampsia

Executive Summary: Hypertension in Pregnancy, American College of Obstetricians and Gynecologist, Obstet Gynecol 2013;122:1122-31. Copyright permission received.

10

ACOG Executive Summary on Hypertension In Pregnancy, Nov 2013


1. The term mild preeclampsia is discouraged for clinical classification. The recommended terminology is: a. preeclampsia without severe features (mild) b. preeclampsia with severe features (severe) 2. Proteinuria is not a requirement to diagnose preeclampsia with new onset hypertension. 3. The total amount of proteinuria > 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia. 4. Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic. 5. Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild).
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ACOG Executive Summary on Hypertension In Pregnancy, Nov 2013


6. Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications. 7. Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension. 8. The postpartum period is potentially dangerous. Patient education for early detection during and after pregnancy is important. 9. Long-term health effects should be discussed.

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Key Clinical Pearl

Forty percent of patients with new onset hypertension or new onset proteinuria will develop classic preeclampsia.

Barton JR, Sibai BM. Prediction and prevention of recurrent preeclampsia. Obstet Gynecol. 2008;112(2 PART 1): 359-372.

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The Deadly Triad


Severe Preeclampsia HELLP Syndrome - Eclampsia Associated with an increased risk of adverse outcomes such as: Placental Abruption

Renal Failure Subcapsular Hepatic Hematoma Preterm Delivery

Fetal or Maternal Death


Recurrent Preeclampsia
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ACOG Practice Bulletin #33, Reaffirmed 2012; ACOG Committee Opinion #514, 2012; Tuffnell D, Jankowitcz D, Lindow S, et al. BJOG 2005;112:875-880.

How Do Women Die Of Preeclampsia?


CA-PAMR Final Cause of Death Among Preeclampsia Cases, 2002-2004 (n=25)
Final Cause of Death Stroke Hemorrhagic Thrombotic Hepatic (liver) Failure Cardiac Failure Number 16 14 2 4 2

%
64.0% (87.5%) (12.5%)
16.0% 8.0% 4.0%

Rate/100,000 1.0

.25

Hemorrhage/DIC Multi-organ failure ARDS

1 1 1

4.0% 4.0%
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Key Clinical Pearl Controlling blood pressure is the optimal intervention to prevent deaths due to stroke in women with preeclampsia.
Over the last decade, the UK has focused QI efforts on aggressive treatment of both systolic and diastolic blood pressure and has demonstrated a reduction in deaths.
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Preeclampsia Mortality Rates in California and UK


Cause of Death among Preeclampsia Cases Stroke Pulmonary/Respiratory Hepatic OVERALL CA-PAMR (2002-04) Rate/100,000 Live Births 1.0 .06 .25 1.6 UK CMACE (2003-05) Rate/100,000 Live Births .47 .00 .19 .66

The overall mortality rate for preeclampsia in California is greater than 2 times that of the UK, largely due to differences in deaths caused by stroke.
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Key Clinical Pearl

The critical initial step in decreasing maternal morbidity and mortality is to administer anti-hypertensive medications within 60 minutes of documentation of persistent (retested within 15 minutes) BP 160 systolic, and/or >105-110 diastolic. Ideally, antihypertensive medications should be administered as soon as possible, and availability of a preeclampsia box will facilitate rapid treatment. In Martin et al., stroke occurred in: 23/24 (95.8%) women with systolic BP > 160mm Hg 24/24 (100%) had a BP 155 mm Hg

3/24 (12.5%) women with diastolic BP > 110mm Hg 5/28 (20.8%) women with diastolic BP > 105mm Hg

Martin JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May. Stroke and Severe Preeclampsia and Eclampsia: A Paradigm Shift Focusing on Systolic Blood Pressure, Obstet Gynecol 2005;105-246.

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Preventing Stroke from Preeclampsia


Blood Pressure Comparisons: Baseline and Pre-stroke
Measure Mean systolic BP
Systolic BP range Systolic BP % > 160 Mean diastolic BP Diastolic BP range Diastolic BP % > 110 Diastolic BP 5 > 105

Pregnancy Baseline (mm Hg) 110.9 + 10.7 (n=25)


90-136 0 67.4 + 6.5 (n=25) 58-80 0 0

Pre-stroke (mm Hg) 175.4 + 9.7 (n=24)


159-198 95.8 (n=27/28) 98.0 + 9.0 (n=24) 81-113 12.5 (n=3) 20.8 (n=5)

Adapted from Martin JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May. Stroke and Severe Preeclampsia and Eclampsia: A Paradigm Shift Focusing on Systolic Blood Pressure, OG 2005;105-246.

47

ACOG Protocol for Labetalol Treatment


LABETALOL:
Threshold Blood Pressure: Systolic 160 OR Diastolic 105-110 Target Blood Pressure: 140-150 - 90-100
If No IV Access: Give Oral Labetalol 200 mg Check BP in 30 minutes; if above threshold, labetalol 200 mg dose If No IV access: Give PO Nifedipine 10 mg

OR

Check BP in 30 minutes; if above threshold, repeat PO nifedipine 10 mg(2)

Seek Consulta on(1)


(Maternal-Fetal Medicine, Cri cal Care, Anesthesia, Internal Medicine)

Switch TO:
Adapted from ACOG Commi ee Opinion #514; (1) MFM, Cri cal Care, Anesthesia, Internal Medicine; (2) Raheem I, Saaid R, Omar S, Tan P. Oral nifedipine versus intravenous labetalol for acute blood pressure control in hypertensive emergencies of pregnancy: a randomised trial. BJOG. 2012;119:78-85.

50

ACOG Protocol for Hydralazine Treatment


HYDRALAZINE
THRESHHOLD BLOOD PRESSURE Systolic 160 OR Diastolic 105-110
TARGET BLOOD PRESSURE 140-160 OR 90-100

ACOG Commi ee Opinion #514, 2011; ACOG Prac ce Bulle n #33. Reaffirmed 2012.

53

Eclampsia

Eclampsia is defined as NEW ONSET grand mal seizures in a woman with preeclampsia Incidence is 1 in 1,000 deliveries in U.S.
Mortality from eclampsia ranges from approximately 1% in the developed world, to as high as 15% in the developing world

Ghulmiyyah L, Sabai BM. Maternal Mortality from Preeclampsia/Eclampsia. Semin Perinatol 2012;36:56-59.

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Characterization of Symptoms Immediately Preceding Eclampsia

3,267 deliveries and 46 cases of eclampsia (1.4%) Most common prodromal neurological symptoms (regardless of the degree of hypertension OR whether the seizure occurred antepartum or postpartum):
Headaches

(80%) Visual disturbance (45%),

20% of women with eclampsia reported no neurologic symptoms before the seizure

Cooray SD, Edmonds SM, Tong S, et al. Characterization of Symptoms Immediately Preceding Eclampsia. Obstetrics & Gynecology, 118(5):1000-1004, November 2011.

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Magnesium Sulfate

Primary effect is via CNS depression Improves blood flow to CNS via small vessel vasodilation Blood pressure after magnesium infusion:

6 gm loading then 2 gm/hr.


sBP
mm Hg

sBP 30 min 143 13

sBP dBP dBP dBP 120 min mm Hg 30 min 120 min 141 14 87 10 79 9 82 9

Mild Group

145 10

Magnesium sulfate should not be considered a antihypertensive medication


54

Belfort M, Allred J, Dildy G. Magnesium sulfate decreases cerebral perfusion pressure in preeclampsia.Hypertens Pregnancy. 2008;27(4):315-27.

Magnesium Sulfate in the Management of Preeclampsia


Magpie Trial Collaboration Group. Do women with preeclampsia, and their babies, benefit from magnesium sulfate?

58% reduction in seizures 45% reduction in maternal death* 33% reduction in placental abruption

*The 45% reduction in maternal death is not statistically significant but clinically important.
Altman D, Carroli G, Duley L, et al. The Magpie Trial: a randomized placebo-controlled trial; Lancet 2002;359:187790.

55

Recommendations for Women Who Should Be Treated With Magnesium


Preeclampsia
without severe features

Severe Preeclampsia X X X X X

Eclampsia

ACOG NICE SOGC CMQCC WHO

** X* X* X

X X X X X

**ACOG Executive Summary, 2013: for preeclampsia without severe features, it is suggested that magnesium sulfate not be administered universally for the prevention of eclampsia.
* Should be considered: Numbers needed to treat (NNT) = 109 for mild, 63 for severe 56

Key Clinical Pearl

Magnesium sulfate therapy for seizure prophylaxis should be administered to any patients with:
Severe

Preeclampsia

Preeclampsia

with severe features i.e., subjective neurological symptoms (headache or blurry vision), abdominal pain, epigastric pain AND
be considered in patients with mild preeclampsia (preeclampsia without severe features)

should

57

Timing of Pregnancy-Related Deaths, CA-PAMR, 2002 to 2004


70 Percent Pregnancy-Related Death 60 50 40 30

63% 87%
17 7

89%

Non-Preeclampsia Deaths (n=129)


10

20
10 0 0

1 6+

1 2 3 4 5 Number of weeks between babys birth and maternal death

80 Percent Preeclampsia Deaths 70 60 50

68%

96%

40
30 20 10 0 0

88%
8% 12% 4%
2 3

Preeclampsia Deaths (n=25)


4%
4

0%
5

4%
6+

Number of weeks between baby's birth and maternal death

59

Late Postpartum Eclampsia


>48 hours following delivery, up to 4 weeks PP Accounts for approximately 15% of cases of eclampsia 63% had no antepartum hypertensive diagnosis The magnitude of blood pressure elevation does not appear to be predictive of eclampsia The most common presenting symptom was headache, which occurred in about 70% of patients; other prodromal symptoms included shortness of breath, blurry vision, nausea or vomiting, edema, neurological deficit, and epigastric pain
66

Al-Safi Z, Imudia A, Filetti L, et al. Delayed Postpartum Preeclampsia and Eclampsia. Obstet Gynecol. 2011;118(5):1102-1107.

Key Clinical Pearls

Early post-discharge follow-up recommended for all patients diagnosed with preeclampsia/eclampsia Preeclampsia Toolkit recommends post-discharge follow-up:
within

3-7 days if medication was used during labor and delivery OR postpartum within 7-14 days if no medication was used

Postpartum patients presenting to the ED with hypertension, preeclampsia or eclampsia should either be assessed by or admitted to an obstetrical service
69

Patient Education Materials

This and many other patient education materials can be ordered from www.preeclampsia.or g/market-place

70

Key Clinical Pearls

Use of preeclampsia-specific checklists, team training and communication strategies, and continuous process improvement strategies will likely reduce hypertensive related morbidity.
Use of patient education strategies, targeted to the educational level of the patients, is essential for increasing patient awareness of signs and symptoms of preeclampsia.
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Preeclampsia: Proposed Measures


(HENs and Quality Collaboratives)

Process: Treatment within 60 minutes per 100 mothers with preeclampsia and severe hypertension (either sBP 160 OR dBP110) Outcome: Number of days of ICU care per 100 mothers with preeclampsia

: Transforming Maternity Care

68

Networking for Effective Change


Doctors Midwives Nurses

Offices/C linics

Hospitals

Public Payers/M edicaid

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: Transforming Maternity Care

Maternal Mortality Rate, California and United States; 1999-2010


18.0
Maternal Deaths per 100,000 Live Births
16.9 14.6 13.1 10.9 9.9 9.8 7.7 United States Rate 9.9 9.7 8.9 10.0 12.1 11.8 11.7 13.3 11.1 9.2 California Rate 15.1 12.7 14.0 11.6 15.5

16.6

16.8

16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0


1999 2000 2001 2002

HP 2020 Objective 11.4 Deaths per 100,000 Live Births


2003 2004 2005 2006 2007 2008 2009 2010

Year
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) for 1999-2010. United States data and HP2020 Objective were calculated using the same methods. U.S. maternal mortality rates are published by the National Center for Health Statistics (NCHS) through 2007 only. Rates for 2008-2010 were calculated using NCHS Final Birth Data (denominator) and CDC Wonder Online Database for maternal deaths (numerator). Accessed at http://wonder.cdc.gov/ucd-icd10.html on Apr 17, 2013 8:00:39 PM. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, April, 2013.

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