PQCNC 2014 Annual Meeting Elliott Main
Transcript of PQCNC 2014 Annual Meeting Elliott Main
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Creating a Team for Maternal Safety
The Case of Preeclampsia
Elliott K. Main, MDMedical Director, CMQCC
Clinical Professor, Obstetrics and Gynecology
University of California, San Francisco, and
Stanford University, Medical School
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: Transforming Maternity Care
Describe national initiatives to reduce perinataland maternal mortality and severe morbidity
Describe the California Maternal Quality Care
Collaborative structure and function
Describe QI approaches to Preeclampsia usedby other organizations
Objectives:
Presenter Disclosure(s): No conflicts to disclose
Supported with grants from the California
HealthCare Foundation and the CDC
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: Transforming Maternity Care
Maternal Mortality Ratios in Selected
Countries over the Past 30 Years
0
5
10
15
20
25
M
aternalMortalityRatio
(per100,0
00birt
hs)
1980 1990
2000 2008
Hogan et al, Lancet 2010; 375: 160923 3
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: Transforming Maternity Care
Literature review and
over 100 in-depthinterviews and focus
groups
Focus on disparity
(esp African American
women) and onvariation among the
states
Scathing indictment of
US healthcare systemfor maternity care
2010 4
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: Transforming Maternity Care 5
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Maternal Mortality Rate,
California Residents; 1970-2006
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.
HP 2010 Objective4.3 Deaths per 100,000 Live Births
MaternalDeathsper100,0
00LiveBirths
ICD-10ICD-8 ICD-9
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Maternal Mortality Rate, California and United
States; 1999-2010
11.1
7.7
10.0
14.6
11.8 11.7
14.010.9
9.7
11.6
9.2
16.9
8.9
15.1
13.1
12.19.99.9
9.8
13.3
12.7
15.5 16.816.6
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
California Rate
United States Rate
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 WonderOnline 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.
HP 2020 Objective11.4 Deaths per 100,000 Live Births
M
aternalDeathsper100,0
00LiveBirths
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Maternal Mortality Rates by Race/Ethnicity,
California Residents; 1999-2006
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.
M
aternalDeathsper100,0
00LiveBirths
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Maternal Mortality and Severe MorbidityApproximate distributions, compiled from multiple studies
CauseMortality(1-2 per
10,000)
ICU Admit(1-2 per
1,000)
Severe Morbid
(1-2 per100)
VTE and AFE 15% 5% 2%
Infection 10% 5% 5%
Hemorrhage 15% 30% 45%
Preeclampsia 15% 30% 30%
Cardiac Disease 25% 20% 10%
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Maternal Mortality and Severe MorbidityApproximate distributions, compiled from multiple studies
CauseMortality(1-2 per
10,000)
ICU Admit(1-2 per
1,000)
Severe Morbid
(1-2 per100)
VTE and AFE 15% 5% 2%
Infection 10% 5% 5%
Hemorrhage 15% 30% 45%
Preeclampsia 15% 30% 30%
Cardiac Disease 25% 20% 10%
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Maternal Mortality and Severe MorbidityApproximate distributions, compiled from multiple studies
CauseMortality(1-2 per
10,000)
ICU Admit(1-2 per
1,000)
Severe Morbid
(1-2 per100)
VTE and AFE 15% 5% 2%
Infection 10% 5% 5%
Hemorrhage 15% 30% 45%
Preeclampsia 15% 30% 30%
Cardiac Disease 25% 20% 10%
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Maternal Mortality and Severe MorbidityApproximate distributions, compiled from multiple studies
CauseMortality(1-2 per
10,000)
ICU Admit(1-2 per
1,000)
Severe Morbid
(1-2 per100)
VTE and AFE 15% 5% 2%
Infection 10% 5% 5%
Hemorrhage 15% 30% 45%
Preeclampsia 15% 30% 30%
Cardiac Disease 25% 20% 10%
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: Transforming Maternity Care
Our 3 Overlapping but
Non-identical Frameworks
Public
Health
SafetyQuality
Different professional
groups with different
trainings and world views
Different agendas andpriorities
Different frames and
models
Far and away thegreatest impact occurs
when we work together!!= Outcomes
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CoIIN to Reduce Infant Mortality
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%
5 Priorities to ReduceInfant Mortality and
Improve Birth Outcomes
Maternal Child Health-Branch
Initially in Regions IV and VI now national
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National Maternal Health Initiative:
Strategies to Improve
Maternal Health And SafetyMay 5th2013
New Orleans, LA
Society for Maternal-Fetal
Medicine (SMFM)
Maternal Child Health Branch (MCH-B)
Division of Reproductive Health
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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
aprotocol and bundle, not theprotocol
--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 ProcessDavid Lagrew
Common issues in introducing change (safety bundles)
Maternal Early Warning Criteria - Jill Mhyre
Criteria to identify women who requireimmediate 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 SupportCynthia Chazotte
Support resources for all those involved in a severe
maternal morbidity or mortality18
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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 yearsamong the following agencies:
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MaternalSafety
Obstetricians(ACOG/SMFM/
ACOOG)
Creating the Collaborative for Change
Nurses(AWHONN)
Family Practice
(AAFP)
Midwives
(ACNM)
Hospitals
(AHA, VHA)
OB Anesthesia
(SOAP)
Birthing Centers(AABC)
Safety,
Credentials
(TJC)
Blood Banks
(AABC)
Perinatal Quality
Collaboratives
(many)
Federal
(MCH-B, CDC,CMS/CMMI)
State
(AMCHP, ASTHO,MCH)
Direct Providers
Nurse
Practitioners
(NPWH)
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122(4):735-736, October 2013
Editorial:
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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 23
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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 26
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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 reviews27
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: Transforming Maternity Care
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
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: Transforming Maternity Care
CMQCC and CPQCC
Mission: Data-driven QI for mothers and newbornsCalifornia 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
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: Transforming Maternity Care
CMQCC Key Partner/StakeholdersState 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,
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: Transforming Maternity Care
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
Current Collaboratives:Prevention of Central line infections
Reduction of VLBW LOS
www.cpqcc.org
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: Transforming Maternity Care
CMQCC Toolkits and Collaboratives
Maternal Mortality
and Morbidity
Hemorrhage
Preeclampsia
CV Disease*
DVT Prevention*
National Quality
Measures
Early Elective
Delivery
Antenatal Steroids
First Birth
Cesarean Delivery*
*Currently under development
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: Transforming Maternity Care
Networking for Effective Change
Doctors
Nurses
Hospitals
MCH/State
Payers/Medicaid
Public
Offices/Clinics
Midwives
1) Engage each from
the beginning2) Evaluate the
project from each
viewpoint
3) Create a work
plan for each
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Everyones nightmare
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QI Topic 1: OB Hemorrhage
Statewide CMQCC OB Hemorrhage QITaskforce 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
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: Transforming Maternity Care
Open Access Toolkit of Best Practices
Guidelines, protocols,
checklists, sample
policies, support materials
Series ofBest Practice
discussions on all OB
hemorrhage topics, from
Accreta to Jehovahs
Witness to Uterotonicagents
www.CMQCC.org
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CMQCC California
Hemorrhage Guidelines
These are open access tools being utilized
in many states
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CMQCC OB Hemorrhage
Care Guidelines
STAGE 1: OB Hemorrhage
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gCumulative Blood Loss >500ml vaginal birth or >1000ml C/S -OR-
Vital signs >15% change or HR 110, BP 85/45, O2 sat 95%Empty bladder: straight cath or place Foley with urimeterType 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, hematomaSurgeon (if cesarean birth and still open)Inspect for uncontrolled bleeding at all levels, esp. broad ligament, posterioruterus, and retained placenta
Consider potential etiology:Uterine atonyTrauma/LacerationRetained placenta
Amniotic Fluid EmbolismUterine InversionCoagulopathyPlacenta AccretaUterine Rupture
Once stabilized: Modified Postpartummanagement with increasedsurveillance
If: Continued bleeding or Continued Vital Sign instability, and
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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 andmassive 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 didactictraining 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 Debriefsfollowing all hemorrhage cases, and MiniRoot Cause Analyses
after severe events utilizing standardized methods/reporting forms
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: Transforming Maternity Care
Obstetric Hemorrhage:
Proposed Measures
(HENs and Quality Collaboratives)
Process: Risk assessment done on every
patient? (sample)
Outcome 1: Total number of units of bloodproducts per 100 mothers giving birth
Outcome 2: Number mothers giving birth who
received 4 units of blood products per 1,000births (massive transfusion)
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QI Topic 2: Preeclampsia
Quality Improvement Opportunity Examples from PAMR:
Missed triggers: high BP (systolic and diastolic), pain, alteredmental status, O2 saturation, fetal distress
Underutilization of Magnesium SO4 and anti-hypertensive
medications
Difficulties getting physician to the bedside, and obtaining
consultations Location of careissues involving Postpartum, ED and PACU
Key Supports:
The Joint Commission Sentinel Alert #44: Preventing Maternal
Death (2010) ACOG Committee Opinion #514: Emergent Therapy for Acute-
Onset, Severe Hypertension with Preeclampsia or Eclampsia
(Dec 2011)
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Executive Summary:
Hypertension in pregnancy
American College of Obstetricians
and Gynecologists,
Obstet Gynecol 2013;122:1122-31
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Di i C i i f P l i
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Executive Summary: Hypertension in Pregnancy, American College of Obstetricians and
Gynecologist, Obstet Gynecol 2013;122:1122-31. Copyright permission received. 9
Diagnosis Criteria for Preeclampsia
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Diagnosis of Severe Preeclampsia
Executive Summary: Hypertension in Pregnancy, American College of Obstetricians and Gynecologist, ObstetGynecol 2013;122:1122-31. Copyright permission received. 10
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ACOG Executive Summary on Hypertension
In Pregnancy, Nov 2013
1. The term mildpreeclampsia is discouraged forclinical 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 preeclampsiawith new onsethypertension.
3. The total amount of proteinuria > 5g in 24 hours has beeneliminated from the diagnosis of severe preeclampsia.
4. Earlytreatment of severehypertension is mandatory at the
threshold levels of 160 mm Hgsystolic or 110 mm Hgdiastolic.
5. Magnesium sulfate for seizure prophylaxis is indicated forseverepreeclampsia and should not beadministereduniversally 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
severeand should be managed at a facility with appropriate
resources for management of serious maternaland neonatal
complications.
7. Induction of labor at 37 weeks is indicated for preeclampsiaandgestational hypertension.
8. The postpartum period is potentially dangerous. Patient
education for early detectionduring and afterpregnancy 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 ornew 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 - EclampsiaAssociated with an increased risk of adverse outcomes
such as: Placental Abruption
Renal Failure
Subcapsular Hepatic Hematoma
Preterm Delivery
Fetal or Maternal Death
Recurrent Preeclampsia
ACOG Practice Bulletin #33, Reaffirmed 2012; ACOG Committee Opinion #514, 2012; Tuffnell
D, Jankowitcz D, Lindow S, et al. BJOG 2005;112:875-880. 13
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CA-PAMR Final Cause of Death Among
Preeclampsia Cases, 2002-2004 (n=25)Final Cause of Death Number % Rate/100,000
Stroke
HemorrhagicThrombotic
16
142
64.0%
(87.5%)(12.5%)
1.0
Hepatic (liver) Failure 4 16.0% .25
Cardiac Failure 2 8.0%Hemorrhage/DIC 1 4.0%
Multi-organ failure 1 4.0%
ARDS 1 4.0%
How Do Women Die Of Preeclampsia?
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Controlling blood pressure
is the optimal intervention
to prevent deaths due to stroke
in women with preeclampsia.
Key Clinical Pearl
Over the last decade, the UK has focusedQI efforts on aggressive treatment of both
systolic and diastolic blood pressure and
has demonstrated a reduction in deaths.
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P l i M t lit R t
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Preeclampsia Mortality Rates
in California and UKCause of Death
among PreeclampsiaCases
CA-PAMR (2002-04)
Rate/100,000Live Births
UK CMACE (2003-05)
Rate/100,000Live Births
Stroke 1.0 .47
Pulmonary/Respiratory .06 .00
Hepatic .25 .19
OVERALL 1.6 .66
The overall mortality rate for
preeclampsia in Californiais greater than 2 times that of the UK,
largely due to differences in deaths
caused by stroke.27
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Key Clinical Pearl
Thecritical 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. 48
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Measure Pregnancy Baseline(mm Hg)
Pre-stroke(mm Hg)
Mean systolic BP 110.9 + 10.7 (n=25) 175.4 + 9.7 (n=24)
Systolic BP range 90-136 159-198
Systolic BP % > 160 0 95.8 (n=27/28)
Mean diastolic BP 67.4 + 6.5 (n=25) 98.0 + 9.0 (n=24)
Diastolic BP range 58-80 81-113
Diastolic BP % > 110 0 12.5 (n=3)
Diastolic BP 5 > 105 0 20.8 (n=5)
Preventing Stroke from PreeclampsiaBlood Pressure Comparisons: Baseline and Pre-stroke
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
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LABETALOL:
Threshold Blood Pressure:
Systolic 160 OR Diastolic 105-110
T a r g et B l o od P r e s s ur e :
140-150 - 90-100
A d a p te d f r o m AC O G C o m m i e e O pi n i o n # 5 1 4 ; (1 ) M F M , C r i c a l C a r e , A n e s th e s i a, I n t er n a l M e d i c i ne ; ( 2 ) R a h ee m I , Sa a i d R , O m ar S , T an
P . O r a l n i f e di p i n e v e r s us i n t r av e n o us l a b e ta l o l f o r a c u t e b l o o d p r e s s ur e c o n t ro l i n h y p e rt e n s iv e e me r g e nc i e s o f pr e g n an c y : a
r a n d om i s e d t r i a l . BJOG. 2 0 1 2 ; 1 1 9 :7 8 - 8 5 .
Switch
TO:
I f N o I V A cc e ss :
Give Oral Labetalol
2 00 m g
C h ec k B P i n 3 0
minutes; if abovet h re s ho l d,
labetalol 200 mg
dose
S ee k C on su lt a o n(1 )
( M a te r n a l- F e t al M e d ic i n e , C r i c a l
C are, Anesthesia, Internal Medicine)
I f N o I V a cc e s s :
G i ve P O N i fe d ip i ne
10 mg
Check BP in 30
m i n u te s ; i f a b ov et h r e sh o l d, r e p e at P O
n i f e di p i n e 1 0 m g(2)
OR
ACOG Protocol for Hydralazine
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Treatment
HYDRALAZINE
T H RE S HH OL D B L OO D P R ES S UR ES ys to li c 1 60 O R D ia st ol ic 1 05 -1 10
T A RG E T B L OO D P RE S SU R E1 4 0- 1 60 O R 9 0 -1 0 0
A C OG C o mm i e e O p in i on # 5 14 , 2 0 11 ; A C OG P r ac c e B ul l e n # 3 3. R ea ff i rm e d 2 0 12 .
53
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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 ashigh as 15% in the developing world
Ghulmiyyah L, Sabai BM. Maternal Mortality from Preeclampsia/Eclampsia. Semin Perinatol
2012;36:56-59. 42
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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 orpostpartum):
Headaches (80%)
Visual disturbance (45%),
20% of women with eclampsia reported noneurologic 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. 43
Magnesium Sulfate
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g
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.
sBPmm Hg
sBP
30 min
sBP
120 min
dBPmm Hg
dBP
30 min
dBP
120 min
Mild
Group
145
10
143
13
141
14
87
10
79
9
82
9
Belfort M, Allred J, Dildy G. Magnesium sulfate decreases cerebral perfusion pressure in
preeclampsia.Hypertens Pregnancy. 2008;27(4):315-27.
Magnesium sulfate should notbe considered a
antihypertensivemedication
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Magnesium Sulfate in the Management
of Preeclampsia
Magpie 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
Altman D, Carroli G, Duley L, et al. The Magpie Trial: a randomized placebo-controlled trial; Lancet
2002;359:187790.
*The 45% reduction in maternal death is not statistically significant but
clinically important.
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Recommendations for Women
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Recommendations for Women
Who Should Be Treated With Magnesium
Preeclampsiawithout severefeatures
SeverePreeclampsia Eclampsia
ACOG ** X X
NICE X XSOGC X* X X
CMQCC X* X X
WHO 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 mi ld, 63
forsevere
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Key Clinical Pearl
Magnesium sulfate therapy for seizure prophylaxisshould be administered to any patients with:
Severe Preeclampsia
Preeclampsia withsevere featuresi.e., subjectiveneurological symptoms (headache or blurry vision),abdominal pain, epigastric pain AND
should be consideredin patients with mildpreeclampsia (preeclampsia wi thout severefeatures)
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Timing of Pregnancy-Related Deaths
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Timing of Pregnancy-Related Deaths,
CA-PAMR, 2002 to 2004
68%
8%12%
4% 4%0%
4%
0
10
20
30
40
50
60
70
80
0 1 2 3 4 5 6+
Number of weeks between baby's birth and maternal death
PercentPreeclampsiaDeaths
88%
87%
Non-PreeclampsiaDeaths
(n=129)
Preeclampsia
Deaths
(n=25)
96%
89%
63%
17
71 1 1
10
0
10
20
30
40
50
60
70
0 1 2 3 4 5 6+
Perc
entPregnancy-RelatedDeath
Number of weeks between babys birth and maternal death
59
Late Postpartum Eclampsia
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Late Postpartum Eclampsia
>48 hours following delivery, up to 4 weeks PP
Accounts for approximately 15% of cases ofeclampsia
63% had no antepartum hypertensive diagnosis
The magnitude of blood pressure elevation doesnotappear to be predictive of eclampsia
The most common presenting symptom was
headache, which occurred in about 70% of patients;
other prodromal symptoms included shortness ofbreath, blurry vision, nausea or vomiting, edema,
neurological deficit, and epigastric painAl-Safi Z, Imudia A, Filetti L, et al. Delayed Postpartum Preeclampsia and Eclampsia. Obstet
Gynecol. 2011;118(5):1102-1107. 66
K Cli i l P l
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Early post-discharge follow-up recommended for
all patientsdiagnosed withpreeclampsia/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
Postpartumpatients presenting to the ED withhypertension, preeclampsia or eclampsia should
either be assessed by oradmitted to anobstetrical service
Key Clinical Pearls
69
Patient Education Materials
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Patient Education Materials
This and many other
patient education
materials can be
ordered fromwww.preeclampsia.or
g/market-place
70
http://www.preeclampsia.org/market-placehttp://www.preeclampsia.org/market-placehttp://www.preeclampsia.org/market-placehttp://www.preeclampsia.org/market-placehttp://www.preeclampsia.org/market-placehttp://www.preeclampsia.org/market-place -
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Key Clinical Pearls
Use of preeclampsia-specific checklists,team training and communicationstrategies, and continuous processimprovement strategies will likely reduce
hypertensive related morbidity.
Use of patient education strategies,targeted to the educational level of the
patients, is essential for increasing patientawareness of signs and symptoms ofpreeclampsia.
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P l i
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: Transforming Maternity Care
Preeclampsia:
Proposed Measures
(HENs and Quality Collaboratives)
Process: Treatment within 60 minutes per 100
mothers with preeclampsia and severehypertension (either sBP 160 OR dBP110)
Outcome: Number of days of ICU care per 100
mothers with preeclampsia
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: Transforming Maternity Care
Networking for Effective Change
Doctors
Nurses
Hospitals
MCH/State
Payers/Medicaid
Public
Offices/Clinics
Midwives
Maternal Mortality Rate California and United
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Maternal Mortality Rate, California and United
States; 1999-2010
11.1
7.7
10.0
14.6
11.8 11.7
14.010.9
9.7
11.6
9.2
16.9
8.9
15.1
13.1
12.19.99.9
9.8
13.3
12.7
15.5 16.816.6
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
California Rate
United States Rate
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 WonderOnline 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.
HP 2020 Objective11.4 Deaths per 100,000 Live Births
MaternalDeathsper1
00,0
00LiveBirths
h k
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Thank You!
Visit: CMQCC org