cmqcc preeclampsia tool kit: hypertensive disorders across the lifespan€¦ · 10/12/14 1 cmqcc...

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CMQCC Preeclampsia Tool Kit:

Hypertensive Disorders Across the

Lifespan

Carol J Harvey, MS, BSN, RNC-OB, C-EFM, CS

Northside Hospital

Atlanta – Cherokee - Forsyth

Improving Health Care Response to Preeclampsia: A

California Quality Improvement Toolkit

Available online at www.cmqcc.org

New!

CMQCC PREECLAMPSIA TOOLKIT/PREECLAMPSIA CARE GUIDELINES CDPH-MCAH Approved: 12/20/13

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Grouped Cause of Death 2002-2004 (N=145)

California Pregnancy-Associated Mortality Review (CA-PAMR) Quality Improvement Review Cycle

Grouped Cause of Death Chance to Alter Outcome Strong /Good (%) Some(%) None (%) Total N (%)

Obstetric hemorrhage 69 25 6 16 (11) Deep vein thrombosis/ 53 40 7 15 (10) pulmonary embolism Sepsis/infection 50 40 10 10 (7) Preeclampsia/eclampsia 50 50 0 25 (17) Cardiomyopathy & other 25 61 14 28 (19) cardiovascular causes Cerebral vascular accident 22 0 78 9 (6) Amniotic fluid embolism 0 87 13 15 (10) All other causes of death 46 46 8 26 (18)

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How Do Women Die Of Preeclampsia in CA?

CA-PAMR Final Cause of Death Among Preeclampsia Cases, 2002-2004 (n=25)

Final Cause of Death Number % Rate/100,000 •  Stroke 16 64% 1

Hemorrhagic 14 87.5% Thrombotic 2 12.5%

•  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%

Why is it important?

❖ Complicates 10% pregnancies worldwide ❖ One of the greatest causes of maternal &

perinatal morbidity and mortality ❖  ≈ 50,000 – 60,000 preeclampsia –related deaths

per year worldwide ❖  In the US: Ø  Incidence has increased 25% in US during

past 20 yrs Ø  For every death from preeclampsia, 50 – 100 women

have “near miss” events, significant health risks and costs

New! New!

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Preeclampsia-Eclampsia

Advances for Rapid Response ❖ New Protocols for Antihypertensive Drugs ❖ New Rescue Antihypertensive Agent

ACOG Hypertensive Emergency Treatment Guidelines, CO #514

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ACOG CO #541, Dec. 2011

“Acute-onset, severe hypertension that is accurately measured using standard techniques and is persistent for 15 minutes or more is considered a hypertensive emergency.”

Hypertensive Emergency

❖ Acute-onset ❖ Severe Hypertension ◆ Systolic >160 mm Hg, OR ◆ Diastolic >110 mm Hg, ◆ OR Both

❖ Accurately measured using standard techniques and ❖ Persistent for >15 minutes [is considered]

a hypertensive emergency. Emergent therapy for acute-onset, severe hypertension with preeclampsia or eclampsia. Committee Opinion

No. 514. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118: 1465–8

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Link to ACOG CO Tx HYTN Emergency – Preeclampsia-Eclamp

h"p://journals.lww.com/greenjournal/Citation/2011/12000/Commi"ee_Opinion_No__514___Emergent_Therapy_for.53.aspx

❖  Intravenous labetalol and hydralazine* are both considered first-line drugs for the management of acute, severe hypertension in this clinical setting.

❖  Close maternal and fetal monitoring by the physician and nursing staff are advised.

❖  Order sets for the use of labetalol and hydralazine for the initial management of acute, severe hypertension in pregnant or postpartum women with preeclampsia or eclampsia have been developed.

VOL. 118, NO. 6, DECEMBER 2011 OBSTETRICS & GYNECOLOGY 1465

Risk reduction and successful, safe clinical outcomes for women with preeclampsia or eclampsia require avoidance and management of severe systolic and severe diastolic hypertension. How to integrate standardized order sets into everyday safe practice in the United States is a chal-lenge. Increasing evidence indicates that standardization of care improves patient outcomes (1). Introducing into obstetric practice standardized, evidence-based clini-cal guidelines for the management of patients with preeclampsia and eclampsia has been demonstrated to reduce the incidence of adverse maternal outcomes (2, 3). With the advent of pregnancy hypertension guidelines in the United Kingdom, care of maternity patients with preeclampsia or eclampsia improved significantly, and maternal mortality rates decreased because of a reduction in cerebral and respiratory complications (4, 5).

Acute-onset, severe systolic (greater than or equal to 160 mm Hg) or severe diastolic (greater than or equal to 110 mm Hg) hypertension or both can occur in pregnant or postpartum women with any hypertensive disorders during pregnancy. Acute-onset, severe hypertension that is accurately measured using standard techniques and is persistent for 15 minutes or more is considered a hypertensive emergency. This occurs in the second half of gestation in patients not known to have chronic hyper-tension who develop sudden, severe hypertension (ie, with preeclampsia, gestational hypertension, or HELLP

[hemolysis, elevated liver enzymes, low platelets] syn-drome) or, less frequently, in patients with chronic hyper-tension who are developing superimposed preeclampsia with acutely worsening, difficult to control, severe hyper-tension. It is well known that severe hypertension can cause central nervous system injury. Two thirds of the maternal deaths in the most recent Confidential Inquiries report from the United Kingdom for 2003–2005 resulted from either cerebral hemorrhage or infarction (4). The degree of systolic hypertension (as opposed to the level of dia-stolic hypertension or relative increase or rate of increase of mean arterial pressure from baseline levels) may be the most important predictor of cerebral injury and infarction. In a recent case series of 28 women with severe preeclamp-sia and stroke, all but 1 woman had severe systolic hyper-tension (greater than or equal to 160 mm Hg) just before a hemorrhagic stroke, and 54% died, whereas only 13% had severe diastolic hypertension (greater than or equal to 110 mm Hg) in the hours preceding stroke (6). A simi-lar relationship between severe systolic hypertension and risk of hemorrhagic stroke has been observed in nonpreg-nant adults (7). Thus, systolic BP of 160 mm Hg or greater is widely adopted as the definition of severe hypertension in pregnant or postpartum women (8, 9).

Pregnant or postpartum women with acute-onset, severe systolic or severe diastolic hypertension or both require antihypertensive therapy. The goal is not to nor-

Emergent Therapy for Acute-Onset, Severe Hypertension With Preeclampsia or EclampsiaABSTRACT: Acute-onset, persistent (lasting 15 minutes or more), severe systolic (greater than or equal to 160 mm Hg) or severe diastolic hypertension (greater than or equal to 110 mm Hg) or both in pregnant or postpar-tum women with preeclampsia or eclampsia constitutes a hypertensive emergency. Severe systolic hypertension may be the most important predictor of cerebral hemorrhage and infarction in these patients and if not treated expeditiously can result in maternal death. Intravenous labetalol and hydralazine are both considered first-line drugs for the management of acute, severe hypertension in this clinical setting. Close maternal and fetal monitoring by the physician and nursing staff are advised. Order sets for the use of labetalol and hydralazine for the initial man-agement of acute, severe hypertension in pregnant or postpartum women with preeclampsia or eclampsia have been developed.

Committee on Obstetric PracticeThis document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

COMMITTEE OPINIONNumber 514 • December 2011

The American College of Obstetricians and GynecologistsWomen’s Health Care Physicians

Emergent Therapy for Acute-Onset, Severe Hypertension With Preeclampsia or Eclampsia

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Hypertensive Crisis Algorithm

Systolic >160 OR

Diastolic >110

Labetalol 20 mg IV

BP > Threshold?

Labetalol 40 mg IV

BP > Threshold?

Labetalol 80 mg IV

BP > Threshold?

Apresoline 10 mg

Hydralazine 10 mg IV

BP > Threshold?


BP > Threshold?

Labetalol 20 mg IV

BP > Threshold?

Labetalol 40 mg IV

Yes

Repeat BP 10 min

No When BP < threshold, repeat BP: -  every 10 min x 1

hour -  then every 15 min

x 1 hour, -  then every 30 min

x 1 hour, -  then every hour

for 4 hours. Institute additional BP timing per specific order.

When BP < threshold, repeat BP: -  every 10 min x 1





Created from: ACOG, CO #514, Dec 2011

Yes

Repeat BP 10 min

No

Yes

Repeat BP 10 min

No

Yes

Repeat BP 20 min

No

Yes

Repeat BP 20 min

No

Yes

Repeat BP 10 min

No

Labetalol 1st Line

Hydralazine 1st Line

Order Set for Severe Intrapartum or Postpartum Hypertension Initial First-Line Management with Labetalol*

1.  Notify physician if systolic > 160 mm Hg or if diastolic > 110 mm Hg. 2.  Institute fetal surveillance if undelivered and fetus is viable. 3.  Administer labetalol (20 mg IV over 2 minutes). 4.  Repeat BP measurement in 10 minutes; record results. 5.  If either BP > threshold, administer labetalol (40 mg IV over 2 minutes). If BP is below

threshold, continue to monitor BP closely. 6.  Repeat BP measurement in 10 minutes and record results. 7.  If either BP > threshold is, administer labetalol (80 mg IV over 2 minutes). If BP is below

threshold, continue to monitor BP closely. 8.  Repeat BP measurement in 10 minutes and record results. 9.  If either BP > threshold, administer hydralazine (10 mg IV over 2 minutes). If BP is below

threshold, continue to monitor BP closely. 10.  Repeat BP measurement in 20 minutes and record results. 11.  If either BP > threshold, obtain emergency consultation from MFM, IM, anesthesia, or

critical care specialists. 12.  Give additional antihypertensive medication per specific order (Nicardipine). 13.  Once the aforementioned BP thresholds are achieved, repeat BP measurement every 10

minutes for 1 hour, then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and then every hour for 4 hours.

14.  Institute additional BP timing per specific order.

“Box 1”

Emergent therapy for acute-onset, severe hypertension with preeclampsia or eclampsia. Committee Opinion No. 514. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118: 1465–8

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Systolic >160 OR

Diastolic >110

Labetalol 20 mg IV

BP > Threshold?

Labetalol 40 mg IV

BP > Threshold?

Labetalol 80 mg IV

BP > Threshold?

Apresoline 10 mg


BP > Threshold?


BP > Threshold?

Labetalol 20 mg IV

BP > Threshold?

Labetalol 40 mg IV

Yes

Repeat BP 10 min












Yes

Repeat BP 10 min

No

Yes

Repeat BP 10 min

No

Yes

Repeat BP 20 min

No

Yes

Repeat BP 20 min

No

Yes

Repeat BP 20 min

No

Labetalol 1st Line

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1.  Notify physician if systolic BP is greater than or equal to 160 mm Hg or if diastolic BP is greater than or equal to 110 mm Hg.

2.  Institute fetal surveillance if undelivered and fetus is viable. 3.  Administer hydralazine (5 mg or 10 mg IV over 2 minutes). 4.  Repeat BP measurement in 20 minutes and record results. 5.  If either BP threshold is still exceeded, administer hydralazine (10 mg IV over 2

minutes). If BP is below threshold, continue to monitor BP closely. 6.  Repeat BP measurement in 20 minutes and record results. 7.  If either BP threshold is still exceeded, administer labetalol (20 mg IV over 2 minutes).

If BP is below threshold, continue to monitor BP closely. 8.  Repeat BP measurement in 10 minutes and record results. 9.  If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes)

and obtain emergency consultation from MFM, IM, anesthesia, or critical care specialists.

10.  Give additional antihypertensive medication per specific order. 11.  Once the aforementioned BP thresholds are achieved, repeat BP measurement

every 10 minutes for 1 hour, then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and then every hour for 4 hours.

12.  Institute additional BP timing per specific order.

Order Set for Severe IP or PP Hypertension Initial First-Line Management with Hydralazine* “Box 2”


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Systolic >160 OR

Diastolic >110

Labetalol 20 mg IV

BP > Threshold?

Labetalol 40 mg IV

BP > Threshold?

Labetalol 80 mg IV

BP > Threshold?

Apresoline 10 mg


BP > Threshold?


BP > Threshold?

Labetalol 20 mg IV

BP > Threshold?

Labetalol 40 mg IV

Yes

Repeat BP 10 min












Yes

Repeat BP 10 min

No

Yes

Repeat BP 10 min

No

Yes

Repeat BP 20 min

No

Yes

Repeat BP 20 min

No

Yes

Repeat BP 10 min

No

Hydralazine 1st Line

2nd Line Therapy

❖ “Second line alternatives to consider include intravenous labetalol or nicardipine by infusion pump” ❖ Transplacental passage and changes in

umbilical artery Doppler velocimetry are minimal


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Nicardipine HCL

❖  Nicardipine hydrochloride injection is a calcium ion influx inhibitor (slow channel blocker or calcium channel blocker).

❖  Nicardipine hydrochloride produces significant decreases in systemic vascular resistance.

❖  Is indicated for the short-term treatment of hypertension when oral therapy is not feasible or not desirable.

❖  Because the liver extensively metabolizes nicardipine, plasma concentrations are influenced by changes in hepatic function

❖  Nicardipine hydrochloride injection is contraindicated in patients with advanced aortic stenosis because part of the reduced afterload. ◆  Reduction of diastolic pressure in these patients may worsen rather

than improve myocardial oxygen balance. ❖  Pregnancy Category C

Nicardipine HCL

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Nicardipine – Rapid Onset and Peak Action

Drug Half Life (time) Labetalol 5.5 hours Hydralazine 4 hours Nicardipine* 2 to 5 minutes Nifedipine 2 to 5 hours

*Contraindications to the use of nicardipine are hypersensitivity to nicardipine, severe aortic stenosis, hypotension, and shock.

Nij Bijvank, SW (2010). Nicardipine for treatment of severe hypertension in pregnancy. ObGyn Sur 65,5:341-7.

Case Study Example

❖  33 year old G1P0 at 34 weeks ❖  Benign prenatal course until 32 weeks,

when “some elevated BP” noted in antepartum record. Sent home from office with instructions to re-check BP every 2 to 3 days. ❖  Presents to L&D with headache, c/o

decreased fetal movement.

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Case Study Example

❖  Blood pressures now: §  166/116, §  170/108 §  166/115 §  Over 15 minutes, history and physical done –

benign until elevated BP §  No allergies, no chronic disease §  Repeat BPs: 170/104, 168/102, 168/98

Case Study Example

❖ … start Labetalol protocol/guideline

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Case Study Example

❖  Blood pressures now: §  165/90 §  164/86 §  168/88 §  Over 15 minutes, history and physical done –

benign until elevated BP §  No allergies, no chronic disease §  Repeat BPs: 168/88. 166/85

Case Study Example

❖ … start Labetalol protocol/guideline

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Labetalol Algorithm

Systolic >160 OR

Diastolic >110

Labetalol 20 mg IV

BP > Threshold?

Labetalol 40 mg IV

BP > Threshold?

Labetalol 80 mg IV

BP > Threshold?

Apresoline 10 mg


BP > Threshold?


BP > Threshold?

Labetalol 20 mg IV

BP > Threshold?

NICARDIPINE

Yes

Repeat BP 10 min












Yes

Repeat BP 10 min

No

Yes

Repeat BP 10 min

No

Yes

Repeat BP 20 min

No

Yes

Repeat BP 20 min

No

Yes

Repeat BP 20 min

No

Labetalol 1st Line

What major discovery lead to change in BP parameters for severe preeclampsia (lowered from systolic BP 170-180 mmHg to systolic BP 160 mmHg)? A.  Patients had placental abruptions at systolic

BPs of 160 – 170 mmHg. B.  Patients presented with IUFD with systolic

BPs of 160 – 170 mmHg. C.  Patients had strokes with systolic BPs of

160 – 170 mmHg.

Question

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Obstetrics & Gynecology, November 2013, Volume 122, No.5

2013 Classification of Hypertensive Disorders of Pregnancy

❖ Four (4) Categories 1.  Preeclampsia-eclampsia 2.  Chronic hypertension (of any cause) 3.  Chronic hypertension with superimposed

preeclampsia 4.  Gestational hypertension


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Key Change: Proteinuria Not Required for Diagnosis of Preeclampsia

❖  Recognizes the syndronic nature of preeclampsia ❖  The disease affects all organ systems


Diagnosis of Preeclampsia

❖  Hypertension ◆  Systolic BP of 140 mmHg or higher, OR ◆  Diastolic BP of 90 mmHg or higher

PLUS One of the Following: The disease affects all organ systems; thus, preeclampsia is diagnosed as hypertension with any one of the following: ❖  Proteinuria [>300 mg protein/24 urine collection*, or a protein/

creatinine ratio of >0.3 (each measured by mg/dL)] ◆  *collection may be extrapolated from timed tests;

❖  Thrombocytopenia (platelets <100,000/microliter) ❖  Impaired liver function (increased serum liver transaminases to

twice normal values) ❖  Progressive renal insufficiency (new development/no prior renal

disease; serum creatinine >1.1 mg/dL, or doubling of serum creatinine)

❖  Pulmonary edema ❖  New-onset cerebral or visual disturbances


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Preeclampsia Diagnosis

❖ In the absence of proteinuria ◆ Thrombocytopenia ◆ Impaired liver function ◆ New development of renal insufficiency ◆ Pulmonary edema ◆ New-onset cerebral or visual disturbances


Severe* Features of Preeclampsia

❖  Hypertension ◆  Systolic BP of 160 mmHg or higher, or ◆  Diastolic BP of 110 mmHg or higher

❖  Thrombocytopenia (platelets <100,000/microliter) ❖  Impaired liver function (increased serum liver

transaminases to twice normal values) ❖  Progressive renal insufficiency (new development/no

prior renal disease; serum creatinine >1.1 mg/dL, or doubling of serum creatinine)

❖  Pulmonary edema ❖  New-onset cerebral or visual disturbances

*Proteinuria >5 grams/24 hours has been removed; fetal growth restriction has been removed as a finding – due to similar management independent of causation.


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Chronic Hypertension

❖ “Hypertension that predates pregnancy”


Gestational Hypertension

❖ “Gestational hypertension is BP elevation after 20 weeks of gestation in the absence of proteinuria or the aforementioned systemic findings.”


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Superimposed Preeclampsia

❖ “Superimposed preeclampsia is chronic hypertension in association with preeclampsia.”


Summary

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Carol Harvey

Thank you, for your attention.

cmqcc preeclampsia tool kit: hypertensive disorders across the lifespan€¦ · 10/12/14 1 cmqcc...

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