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10/23/2014Updates in the Diagnosis &Management of Preeclampsia andHypertensive Disorders of PregnancyACOG and CMQCC GuidelinesI have no financial disclosures to reportYair Blumenfeld, MDAssistant ProfessorDepartment of Obstetrics & GynecologyStanford University School of Medicine2014 Guidelines for theManagement of Hypertensionin Pregnancyfrom ACOG and CMQCCMaurice L. Druzin, MDProfessor and Vice-ChairDepartment of Obstetrics and GynecologyDivision of Maternal Fetal MedicineStanford University Medical CenterAssociate Dean for Academic AffairsStanford University School of MedicineLearning objectives To review the most current recommendations for the diagnosis andmanagement of hypertensive disorders of pregnancy from ACOGand the California Preeclampsia Task Force (PTF) of CMQCC. To review the impact of hypertensive disorders of pregnancy onmaternal and perinatal morbidity and mortality. To delineate the most common causes of maternal morbidity andmortality secondary to hypertensive disorders of pregnancy. To outline a management algorithm to optimize care for patientswith hypertensive disorders of pregnancy.1
10/23/2014How often do you encounterpreeclamspia in your practice?1.2.3.4.Almost dailyApproximately once per weekAt least once per monthRarely, approximately a handfulof times per year“Over the past year, I have seenpreeclampsia mismanaged either bythe OB provider, nurse, oranesthesiologist”35%1. True2. False30%25%52%10%12348%4125“In my hospital, the entire care team(OB providers, nursing,anesthesiology) is dedicated tomanaging acute severe hypertensionrapidly”74%6“I’ve had enough of preeclampsiatalks, I’m going out to get somecoffee outside – see ya!”1. True2. False1. True2. False90%26%10%1271282
10/23/2014The summaryExecutive Summary:Hypertension in Pregnancy Classification: 1) Preeclampsia (PE) 2) Chronic hypertension (CHTN) 3) CHTN PE 4) Gestational hypertensionAmerican College ofObstetricians and Gynecologists Management: 1) Blood pressure control! 2) Seizure prevention3) Delivery - 34 weeks vs. 37 weeks4) Post partum surveillanceJames Martin, Jr, MDObstet Gynecol 2013;122:1122-31Improving Health Care Response toPreeclampsia: A California QualityImprovement ToolkitFunding for the development of this toolkit was provided by:Federal Title V block grant funding from the California Department of Public Health; Maternal,Child and Adolescent Health Division and Stanford University.11Preeclampsia Task Force MembersMaurice Druzin, MD – StanfordLarry Shields, MD – Dignity HealthElliott Main, MD – CMQCCBarbara Murphy, RN – CMQCCTom Archer, MD – UCSDOcean Berg, RN, CNS – SF General HospitalBrenda Chagolla, RNC, CNS – UC DavisHolly Champagne, RNC, CNS – KaiserMeredith Drews – Preeclampsia FoundationRacine Edwards-Silva, MD – UCLA Olive ViewKristi Gabel, RNC CNS – RPPC SacramentoThomas Kelly, MD – UCSDNancy Peterson, RNC, PNNP – CMQCCChristine Morton, PhD – CMQCCSarah Kilpatrick, MD – Cedars SinaiRichard Lee, MD – Univ. of Southern CaliforniaAudrey Lyndon PhD, RNC – UC San FranciscoMark Meyer, MD – Kaiser SDValerie Cape – CMQCCEleni Tsigas – Preeclampsia FoundationLinda Walsh, PhD, CNM – UC San FranciscoMark Zakowski, MD – Cedars SinaiConnie Mitchell, MD, MPH – CDPH - MCAHDevelopment of the California Toolkit ‘Improving Health Care Response to Preeclampsia’ was funded by theCalifornia Department of Public Health (CDPH), Center for Family Health, Maternal Child and AdolescentHealth (MCAH) Division, using federal Title V MCH funds.123
10/23/2014Why is preeclampsia important? The incidence of preeclampsia has increased by25% in the United States during the past twodecades.The Scope of the Problem Preeclampsia is a leading cause of maternal andperinatal morbidity and mortality, with anestimated 50,000-60,000 preeclampsia-relateddeaths per year worldwide.Ref: ACOG – HIP, 201313Why is preeclampsia important? For every preeclampsia-related deaththat occurs in the United States, thereare probably 50-100 other women whoexperience “near miss” significantmaternal morbidity that stops short ofdeath but still results in significanthealth risk and health care cost.Cause of U.S. maternal mortality CDC Review of 14 years of coded data: 1979-1992 4024 maternal deaths 790 (19.6%) from preeclampsia90% What can be considered “less thanoptimal” care of patients withpreeclampsia and other hypertensivedisorders of pregnancy reportedlyoccurs with some frequencyworldwide, contributing to maternaland perinatal injury that might havebeen avoidable.Ref: ACOG – HIP, 2013of CVA werefromhemorrhageMacKay AP, Berg CJ, Atrash HK. Obstetrics and Gynecology 2001;97:533-5384
10/23/2014Maternal mortality rate, Californiaresidents: 1970-2010California pregnancy-associated mortalityreview (CA-PAMR) quality improvementreviewcycle1. Identification ofMaternal Deaths per 100,000 Live 181616151515 15101413111011 11 119886511111010979109107612 1211108612985. Evaluation andImplementation ofQI strategies andtools2. Information collection,review by multidisciplinarycommitteeToolkitsDeveloped: Hemorrhage Preeclampsia6HP Objectives – Maternal Deaths ( 42days postpartum) per 100,000 Live Births0197019751980198519901995200020052010SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1970-2010. Maternal mortalityfor California (deaths 42 days postpartum) was calculated using the ICD-8 cause of death classification for 1970-1978, ICD-9 classificationfor 1979-1998 and ICD-10 classification for 1999-2010. Healthy People Objectives: HP2000: 5.0 deaths per 100,000 live births; HP2010: 3.3deaths, later revised to 4.3 deaths per 100,000 live births, and; HP2020: 11.4 deaths per 100,000 live births. Produced by CaliforniaDepartment of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, December, 2012.CA-PAMR causes of death 2002-2004Grouped Cause of Death,per CA-PAMR CommitteePregnancy-RelatedDeathsN (%)Cardiovascular disease29 (20)Cardiomyopathy19 (13)Other cardiovascular10 (7)Preeclampsia/eclampsia25 (17)Obstetric hemorrhage16 (11)Amniotic fluid embolism15 (10)DVT/ PE15 (10)Other45 (31)TOTAL4. Strategies to improvecare and reducemorbidity and mortality3. Cause of Death,Contributing Factors andQuality Improvement (QI)Opportunities identifiedMaternal morbidity and Mortality: PreeclampsiaAbout 8 Preeclampsia Related Mortalities/2007 in CANear Misses: 380/year(ICU admissions)40-50x400-500x145Pregnancy-Related Mortality Rate: 1.6 deaths /100,000 live rtumlength of stay)Source: 2007 All-California Rapid Cycle Maternal/Infant Database for CA Births: CMQCC5
10/23/2014Impact of hypertension in CA-PAMRcohort, 2002-2004CA-PAMR: Chance to alter outcomegrouped cause of death; 2002-2004 (N 145)Grouped Cause of DeathChance to Alter OutcomeStrong / SomeGood (%) (%) Cohort of pregnancy-related deaths, N 145– 25 (17%) of deaths were grouped as “Preeclampsia/Eclampsia” cause ofdeath Over half of all pregnancy-related deaths had HTN diagnoses– 50 (34%) had inpatient diagnosis of HTN– 57 (39%) had any diagnosis of HTN (inpatient, prenatal, preexisting) New best practice recommendations are greatly neededto guide clinicians in the care of women with all forms ofpreeclampsia and hypertension that occur duringpregnancy, particularly women with acute severehypertension and superimposed preeclampsia. Identification of patients with severe forms ofpreeclampsia continues to challenge clinicians.Ref: ACOG – HIP, 2013None(%)TotalN (%)Obstetric hemorrhage6925616 (11)Deep vein thrombosis/pulmonary embolism5340715 (10)Sepsis/infection50401010 (7)Preeclampsia/eclampsia5050025 (17)Cardiomyopathy and othercardiovascular causes25611428 (19)Cerebral vascular accident220789 (6)Amniotic fluid embolism0871315 (10)All other causes of death4646826 (18)Total (%)404812145 Also needed is a system for continually updating theseguidelines and integrating them into daily obstetricpractice. Improved patient education and counseling strategiesare needed to convey more effectively the dangers ofpreeclampsia and hypertension and the importance ofearly detection to women with varying degrees ofhealth literacy. Research on preeclampsia and other hypertensivedisorders of pregnancy in both the laboratory andclinical arenas require continued emphasis andfunding.Ref: ACOG – HIP, 20136
10/23/2014Classification of hypertensivedisorders of pregnancy The task force chose to continue using the classification schemafirst introduced in 1972 by the College and modified in the 1990and 2000 reports of the Working Group of the National HighBlood Pressure Education Program, ASH and ACOG PracticeBulletins.Classification, Diagnosis &Management Although the task force has modified some of the componentsof the classification, this basic, precise and practicalclassification was used which considers hypertension duringpregnancy in only four categories.Ref: ACOG – HIP, 201325Diagnostic criteria for preeclampsiaClassification of hypertensivedisorders of pregnancy1) Preeclampsia-eclampsia after 20 weeks2) Chronic hypertension (of any cause) predating pregnancy3) Chronic hypertension with superimposed preeclampsia4) Gestational hypertension after 20 weeksRef: ACOG – HIP 2013Executive Summary: Hypertension in Pregnancy, American College of Obstetricians andGynecologist, Obstet Gynecol 2013;122:1122-31. Copyright permission received.7
10/23/2014Key clinical pearlForty percent of patients withnew onset hypertension ornew onset proteinuria will developclassic preeclampsia.Barton JR, Sibai BM. Prediction and prevention of recurrent preeclampsia. ObstetGynecol. 2008;112(2 PART 1): 359-372.Laboratory evaluation of preeclampsiaKey clinical pearlPatients presenting with vague symptoms of: headacheabdominal painshortness of breathgeneralized swellingcomplaints of “I just don’t feel right”should be evaluated for atypicalpresentations of preeclampsia or “severefeatures”Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol.May 2009;200(5):481 e481-487.Diagnosis of preeclampsia withsevere features Initial lab studies should include:– CBC with platelet count– AST, ALT, LDH (hemolysis)– Creatinine, Bilirubin, Uric acid, Glucose For women with acute abdominal pain, add:– Serum amylase, lipase and ammonia*5 grams proteinuria eliminated as a criterionExecutive Summary: Hypertension in Pregnancy, American College of Obstetricians and Gynecologist, Obstet Gynecol2013;122:1122-31. Copyright permission received.8
10/23/2014Do not wait when a patient hassevere-range hypertension! Acute onset, persistent (lasting 15 min or more),severe systolic ( 160 mm Hg) or severe diastolichypertension ( 110 mm Hg) or both in pregnant orpostpartum women with preeclampsia/eclampsiaconstitutes a hypertensive emergency* and it isinadvisable to wait 4 hours for treatment.The deadly triadSevere preeclampsia - HELLP syndrome - EclampsiaAssociated with an increased risk of adverse outcomes: Placental Abruption Renal Failure Sub-capsular Hepatic Hematoma Preterm Delivery Fetal or Maternal Death Recurrent Preeclampsia*Emergent Therapy for Acute-Onset, Severe Hypertension With Preeclampsia or Eclampsia, ACOG CommitteeOpinion, # 514, December 2011ACOG executive summary onhypertension in pregnancy, Nov 20131. 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)ACOG Practice Bulletin #33, Reaffirmed 2012; ACOG Committee Opinion #514, 2012;Tuffnell D, Jankowitcz D, Lindow S, et al. BJOG 2005;112:875-880.Cause of U.S. maternal mortality CDC Review of 14 years of coded data: 1979-1992 4024 maternal deaths 790 (19.6%) from preeclampsia2. Proteinuria is not a requirement to diagnose preeclampsia with newonset hypertension.90%of CVA werefromhemorrhage3. The total amount of proteinuria 5g in 24 hours has been eliminatedfrom the diagnosis of preeclampsia with severe features.4. Early treatment of severe hypertension is mandatory at the thresholdlevels of 160 mm Hg systolic or 110 mm Hg diastolic.MacKay AP, Berg CJ, Atrash HK. Obstetrics and Gynecology 2001;97:533-5389
10/23/2014Preeclampsia mortality ratesin California and UKHow do women die of preeclampsia in CA?CA-PAMR Final Cause of Death AmongPreeclampsia Cases, 2002-2004 (n 25)Final Cause of .0%Hemorrhage/DIC14.0%Multi-organ failureARDS2111.087.5%12.5%Hepatic (liver) FailureCardiac FailureRate/100,000Cause of Death amongPreeclampsia 4.0%CA-PAMR (2002-04)Rate/100,000Live Births1.0.06.25OVERALL1.6UK CMACE (2003-05)Rate/100,000Live Births.47.00.19.66The overall mortality rate forpreeclampsia in Californiais greater than 2 times that of the UK,largely due to differences in deathscaused by stroke.37Key clinical pearlControlling blood pressureis the optimal interventionto prevent deaths due to strokein women with preeclampsia.Over the last decade, the UK has focused QIefforts on aggressive treatment of both systolicand diastolic blood pressure and hasdemonstrated a reduction in deaths.38Gestational age groups of CAPAMR deaths, 2002 to 2004GESTATIONALAGE GROUPS2002-2004 CA-PAMRPREECLAMPSIADEATHS (N 25)N (%)CA-PAMRNON-PREECLAMPSIADEATHSN (%) 24 weeks0 (0)2 (2%)24-31w6d2 (8%)13 (11%)32-36w6d12 (48%)29 (24%) 37 weeks11 (44%)76 (63%)TOTAL25120Early Preterm Birth Preeclampsia Deaths:36% (n 9) were 34 weeks gestation10
10/23/2014Key clinical pearlIn patients withpreterm preeclampsia with severe features,the disease can rapidly progress to significantmaternal morbidity and/or mortality.Expectant management in pregnancies withpreeclampsia with severe features 24-34 weeksExpectant management recommendations:With stable maternal/fetal conditions, continued pregnancyshould be undertaken only at facilities with adequatematernal and neonatal intensive care resourcesAdminister corticosteroids for fetal lung maturity benefitACOG Executive Summary: Hypertension in Pregnancy. Obstet Gynecol 2013;122:1122-31Management of suspected preeclampsiawith severe features 34 weeks gestationExpectant management of pregnancieswith preeclampsia 34 weeks gestationMaternal Stabilization refers to: Seizure prophylaxis BP control Adequate maternal cardio-pulmonary function AND Consultation with: NICU MFM Anesthesia and/or Critical care servicesInitial 24-48 hours observation Initiate antenatal corticosteroids if not previously administeredInitiate 24 hour urine monitoring as appropriateOngoing assessment of maternal symptoms, BP, urine outputDaily lab evaluation (minimum) for HELLP and renal functionMay observe on an antepartum ward after initial evaluationProceed to delivery for: Recurrent severe hypertension despite therapy Other contraindications to expectant managementAntenatal corticosteroid treatment completed: Expectant management not contraindicated Consider ongoing in-patient expectantmanagementAdapted from Sibai BM. Evaluation and management of severe preeclampsia before 34 weeks’gestation. American Journal of Obstetrics & Gynecology, September 2011, pg. 191-198.11
10/23/2014Expectant management of pregnancies 34 weeks gestation(From CMQCC Preeclampsia Toolkit, 2013)ACOG task force recommendations For women with gestational hypertension, lessthan 160/110 or preeclampsia without severefeatures at or beyond 37 0/7 weeks ofgestation, delivery rather than continuedobservation is suggested.Ref: Koopmans CM, et al. Induction of labour versus expectant monitoring forgestational hypertension or mild preeclampsia after 36 weeks gestation.(HYPITAT). Lancet 2009;374:979-88Factors contributing to pregnancyrelated deaths, CA-PAMR 2002-2004Contributing Factor(at least one factor probably or definitelycontributed)OVERALLPATIENT FACTORSUnderlying significant medical conditionsPreeclampsiaN (%)25 (100%)16 (64%)8 (50%)TOTALN (%)129 (89%)104 (72%)40 (39%)Delay or failure to seek care10 (63%)27 (26%)Lack of understanding the importance of ahealth event9 (56%)16 (15%)HEALTHCARE PROFESSIONALSDelay in diagnosisUse of ineffective treatmentMisdiagnosisFailure to refer or seek consultationHEALTHCARE FACILITY24 (96%)115 (79%)19 (79%)48 (42%)22 (92%)13 (54%)6 (25%)12 (48%)Key clinical pearlAn organized tool to identify “clinicalsigns,” of high concern or triggers canaid clinicians to recognize and respondin a more timely manner to avoiddelays in diagnosis and treatment.62 (54%)36 (31%)26 (23%)72 (50%)12
10/23/2014Preeclampsia early recognition toolEclampsia Eclampsia is defined as NEW ONSET grand malseizures in a woman with preeclampsia Incidence is 1 in 1,000 deliveries in U.S. Mortality from eclampsia ranges from approximately1% in the developed world, to as high as 15% in thedeveloping worldGhulmiyyah L, Sabai BM. Maternal Mortality from Preeclampsia/Eclampsia. Semin Perinatol2012;36:56-59.Eclampsia: maternal-perinatal outcome In254 consecutive cases over 12 years 83,720 deliveries, for an incidence of one in 330 49 patients (19%) did not have proteinuria 58 patients (23%) did not have hypertensionSibai BM. Eclampsia VI. Maternal-perinatal outcome in 254 consecutive cases. Am J Obstet GynecolSep 163(3):1049-1054; discussion 1054-1065 1990.Eclampsia: Maternal-perinatal outcomein 254 consecutive cases over 12 years 73 (29%) occurred postpartum. Over half of postpartum cases, (40 cases/16%) occurred in thelate postpartum period ( 48 hrs) 18 of these 40 cases were normotensive; all 18 had symptomsof headache or visual disturbanceSibai BM. Eclampsia VI. Maternal-perinatal outcome in 254 consecutive cases. Am J ObstetGynecol Sep 163(3):1049-1054; discussion 1054-1065 1990.13
10/23/2014Key clinical pearl The critical initial step in decreasing maternal morbidity and mortality is toadminister anti-hypertensive medications within 60 minutes ofdocumentation of persistent (retested within 15 minutes) BP 160 systolic,and/or 105-110 diastolic. Ideally, antihypertensive medications should be administered as soon aspossible, and availability of a “preeclampsia box” will facilitate rapidtreatment. 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 HgMartin JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May. Stroke and Severe Preeclampsia andEclampsia: A Paradigm Shift Focusing on Systolic Blood Pressure, Obstet Gynecol 2005;105-246.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.MildGroup sBPmm HgsBP30 minsBP120 mindBPmm HgdBP30 mindBP120 min145 10143 13141 1487 1079 982 9Magnesium sulfate should not be considered aantihypertensive medicationBelfort M, Allred J, Dildy G. Magnesium sulfate decreases cerebral perfusion pressure inpreeclampsia.Hypertens Pregnancy. 2008;27(4):315-27.Hypertensive medication administration:Oral versus IV First line therapy recommendations for acute treatment of criticallyelevated BP in pregnant women (160/105-110) are with either IVlabetalol or hydralazine. In the event that acute treatment is needed in a patient without IVaccess oral nifedipine may be used (10 mg) and may be repeated in 30minutes. Oral labetalol would be expected to be less effective in acutely loweringthe BP due to its’ slower onset to peak and thus should be used only ifnifedipine is not available in a patient without IV access.ACOG Practice Bulletin #33, Reaffirmed 2012; ACOG Committee Opinion #514,2012; Tuffnell D, Jankowitcz D, Lindow S, et al. BJOG 2005;112:875-880.Magnesium sulfate in themanagement of PreeclampsiaMagpie Trial Collaboration Group. Do women with pre-eclampsia,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 clinicallyimportant.Altman D, Carroli G, Duley L, et al. The Magpie Trial: a randomized placebo-controlledtrial; Lancet 2002;359:1877–90.14
10/23/2014Recommendations for womenwho should be treated with eclampsiaEclampsia**XXwithout severefeaturesX*X*XXXXXXXXXKey clinical pearl Magnesium sulfate therapy for seizure prophylaxis should beadministered to any patients with:– Preeclampsia with “severe features” i.e., subjectiveneurological symptoms (headache or blurry vision),abdominal pain, epigastric pain AND– should be considered in patients with preeclampsiawithout severe features)**ACOG Executive Summary, 2013: for preeclampsia without severe features, it issuggested that magnesium sulfate not be administered universally for theprevention of eclampsia.* Should be considered: Numbers needed to treat (NNT) 109 for “mild”, 63 for“severe”Key clinical pearlPolicy and Procedure: PerinatalInpatient: IVLabetalol/Hydralazine forAcute HypertensionLPCH Approval: March 2014Algorithms for acute treatment of severehypertension and eclampsia should bereadily available or preferably posted in allclinical areas that may encounter pregnantwomen.15
10/23/2014Labor and delivery medication box and doseguidelines for preeclampsia and eclampsiaThe Post-Partum Period62Timing of pregnancy-related deathsCA-PAMR, 2002 to 200463%Percent Pregnancy-Related Death7089%60Non-PreeclampsiaDeaths(n 129)5087%403017201071011100Percent Preeclampsia Deaths807012345Number of weeks between baby’s birth and maternal death68%6 PreeclampsiaDeaths(n 25)96%605088%4030208%1000112%24%4%340%5ACOG task force recommendationspost partum hypertension and preeclampsia For women in whom GHN,PE, orsuperimposed PE is diagnosed, it is suggestedthat BP be monitored in the hospital orequivalent outpatient surveillance beperformed for at least 72 hours postpartumand again 7-10 days after delivery or earlier inwomen with symptoms.4%6 Number of weeks between baby's birth and maternal death16
10/23/2014Key clinical pearlsKey clinical pearls Early post-discharge follow-up recommended for allpatients diagnosed with preeclampsia/eclampsia Preeclampsia Toolkit recommends post-dischargefollow-up: Use of preeclampsia-specific checklists, teamtraining and communication strategies, andcontinuous process improvement strategieswill likely reduce hypertensive relatedmorbidity. Postpartum patients presenting to the ED withhypertension, preeclampsia or eclampsia should eitherbe assessed by or admitted to an obstetrical service Use of patient education strategies, targeted tothe educational level of the patients, isessential for increasing patient awareness ofsigns and symptoms of preeclampsia.– within 3-7 days if medication was used during labor anddelivery OR postpartum– within 7-14 days if no medication was usedPatient education materialsThis and many otherpatient educationmaterials can beordered fromwww.preeclampsia.org/market-placeGetting the job done in your institution Establish tools / new recommendationsEstablish champions and collaboratorsProvide convincing rationale for changeGet providers to adopt the changesProvide convincing evidence that the proposedchanges in clinical care will improve outcome Distribute the convincing rationale and evidence17
10/23/2014For More Informationand toDownload theToolkit Visit our website:www.cmqcc.org Or contact us:info@cmqcc.orgThank youAvailable online atwww.cmqcc.org7018
Blood Pressure Education Program, ASH and ACOG Practice Bulletins . Although the task force has modified some of the components of the classification, this basic, precise and practical classification was used which considers hypertension during pregnancy in only four categories . Ref: ACOG -HIP, 2013 Classification of hypertensive
