EMPOWERED by Data. CONNECTED by Purpose.

HYPERTENSIVE DISEASE IN PREGNANCY:

IMPROVING MATERNAL OUTCOMES

CONTINUING THE JOURNEY

The National Perinatal Information Center is dedicated to the improvement of perinatal health through comparative data analysis, program evaluation, health services research and professional continuing education.

NURSE PLANNER

Purpose/Goal(s) of this Education Activity The purpose/goal(s) of this activity is to enable healthcare providers to expand their knowledge in relation to care of the patient with hypertensive disease in pregnancy.

1.0 Contact Hour(s) This continuing nursing education activity was approved by the Northeast Multistate Division (NEMSD), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Maine, New Hampshire, New York, Rhode Island, Vermont Nurses Associations are members of the Northeast Multistate Division of the American Nurses Association.

1.0 AMA PRA Category 1 Credit™ Accreditation: Women & Infants Hospital is accredited by the Rhode Island Medical Society to sponsor intrastate continuing education for physicians. Women & Infants Hospital designates this online educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Carolyn L. Wood, PhD, RN, Clinical Nurse Consultant

DISCLOSURES AND SUCCESSFUL COMPLETION OF THIS ACTIVITY

No commercial support has been provided for this activity.

Dr. Tomlinson has identified that in the past he has received grant/research support from Ariosa/Roche and is a consultant for Natera.

No other persons involved in planning or presenting this program has a conflict of interest.

There will be no discussion of off-label usage of any products.

In order to successfully complete this activity and receive 1.0 Contact Hour/1.0 AMA PRA Category 1 Credit™ you must attend/watch the program and return the completed post-test/evaluation to NPIC.

OBJECTIVES

Discuss maternal morbidity and mortality statistics

Discuss definitions, diagnostic criteria, and current management

recommendations Discuss standardization and quality improvement initiatives

Hypertensive Disease in

Pregnancy: Improving

Maternal Outcomes Continuing the Journey

Mark Tomlinson, MD

Providence Women and Children’s Program

Women’s Healthcare Associates/Northwest

Perinatal Center

Propublica Feb 2017 www.propublica.org Lost Mothers Series

Preventing Maternal Mortality

by reducing morbidity

“… the United States has become

the most dangerous industrialized

country to give birth.”

NPR Expose • 33 yr G1 NICU nurse admitted for scheduled induction at

39 6/7 wks

• Multiple BP elevations during labor

– Dr. considered these normal, concerned if BP >180/110

• Uncomplicated NSVD 24 hrs later

• Severe epigastric pain and BP 169/108 within an hour

after birth. Lab work normal

• Stopped checking BP’s approximately 4 hrs pp because

“we know it is high”.

• Recheck 2 hrs later with severe & worsening epigastric

pain. BP was 197/117. Shortly after complained of severe

headache followed by decreased consciousness and

neuro deficits.

• CT showed hemorrhagic stroke. She died shortly after

Maternal Mortality in US

CDC.gov 2016 *per 100,000 live births

Pregnancy Related Maternal Mortality

CDC Pregnancy Mortality Surveillance System

Accessed Feb, 2017

MacDorman, OB & GYN 2016

*per 100,000 live births

International Comparison of

Maternal Mortality

Lancet 2010, 2014

*per 100,000 live births

Cause of Pregnancy Related

Maternal Mortality 2011-2013

CDC Pregnancy Mortality Surveillance System

Accessed June, 2017

Maternal Mortality & Quality of Care Cause of Death Maternal

Mortality

Ratio

(per 100,000

live births)

Percent

Of

Maternal

Deaths

(%)

Avoidable

Death

(%)

Potentially

Avoidable

Death

(%)

Total

(%)

Total

(n=205)

9.7 41 48 89

Cardiovascular

Condition

(n=48)

2.3 23.7 29 63 92

Preeclampsia

(n=35)

1.7 17.4 60 40 100

Hemorrhage

(n=20)

0.9 9.7 70 25 95

Thromboembolism

(n=20)

0.9 9.7 50 45 95

Main, 2015

Factors Contributing to

Mortality in Preeclampsia

Contributing Factor Percentage of Cases

Provider Related

Delayed Response 95

Ineffective Care 70

Misdiagnosis 40

Lack of Continuity of Care 40

Patient Related

Delay in Seeking Care 42

Underlying Medical Condition 39

Lack of Knowledge 39

Obesity 15

Facility Related

Inadequate Knowledge 30

Care Coordination 20

System Issue 25

Main, 2015

HP 2020 Objective – 11.4 Deaths per 100,000 Live Births

Ma

tern

al D

ea

ths

per

10

0,0

00

Liv

e B

irth

s

16.9

6.2

9.2

11.6

9.7

10.9

7.3

7.4

14.0

11.711.8

14.6

10.0

7.7

11.1

22.0

19.9

19.3

16.616.915.5

12.7

13.3

9.8

9.99.9

12.1

13.1

15.1

8.9

0

3

6

9

12

15

18

21

24

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

California Rate

United States Rate

Mate

rna

l D

ea

ths

pe

r 1

00

,00

0 L

ive

Bir

ths

HP 2020 Objective

-------11.4 Deaths-------

per 100,000 Live Births

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Produced by California

Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

Maternal Mortality Rate,

California and United States; 1999-2013

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤

42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the

same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008

through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon March 11, 2015. Produced by California Department of

Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March, 2015.

Moving from Mortality to Morbidity

• Mortality is a rare event that many

providers may never see in a career

• For every maternal death there is more

than 100 cases of severe morbidity

where the patient is “rescued”

• Precursor morbidity usually resolves

without permanent sequelae, the

patients are mostly young and healthy

leading to a disconnect between event

and outcome

Maternal Morbidity

Complication %

HELLP Syndrome 10-20

Placental abruption 1-4

Eclampsia <1

Pulmonary Edema 2-5

Acute renal failure 1-5

Liver failure <1

Stroke Rare

Death Rare

Long term cardiovascular disease

Sibai, Lancet 2005

Neonatal Morbidity

Complication %

Preterm Delivery 15-67

IUGR 10-25

Hypoxic neurologic injury <1

Death 1-2

Adult cardiovascular ds --

Sibai, Lancet 2005

Characteristics of Stroke

Characteristic % of Patients

(n=28)

Postpartum 57.1

Hemorrhagic/arterial 95.8

Multifocal 37.0

SBP ≥160 immediately before 95.8

DBP ≥110 immediately before 12.5

DBP ≥105 immediately before 17.9

Martin 2005

National Estimate of HTN Treatment

• Premier Perspective data base

– Uses coded data

– Includes 15% of all inpatient hospital stays in US – nearly 240,000

patients with preeclampsia

• Evaluated changes in HTN therapy from 2006 to 2015

• Steady increase in antihypertensive therapy from 2006 to

2015

• No difference between hospital teaching status, location,

region

• Older, black, medicaid insurance all more likely to receive

therapy

Cleary, Obstet Gynecol 2018

Rate of Stroke in Patients with Severe

Preeclampsia

0

2

4

6

8

10

12

14

2006-08 2009-11 2013-14

Str

ok

e in

pa

tie

nts

wit

h p

ree

cla

ms

pia

(/

10

,00

0 d

eli

ve

rie

s)

Cleary, Obstet Gynecol 2018

Antihypertensive Therapy in US

0

5

10

15

20

25

30

35

<40 40-<50 50-<60 60-<70 70-<80 >80

Pro

po

rtio

n o

f H

osp

itals

(%

)

Hospital Rate of Antihypertensive Therapy (%)

Cleary, Obstet Gynecol 2018

Classifying Hypertensive Disease

in Pregnancy

• Gestational HTN – SBP ≥140 or DBP ≥ 90 on 2

occasions > 4 hrs apart developing after 20 wks and

returning to normal postpartum

• Preeclampsia – HTN and proteinuria (≥300 mg in 24 hr

or prot/Cr ratio of ≥0.3) or thrombocytopenia, impaired

liver function, or new onset renal insufficiency without

poteinuria

• Chronic HTN – preexisting or identified prior to 20 wks

• Superimposed Preeclampsia – preeclampsia

developing in presence of preexisting HTN or renal

disease ACOG 2002, 2013

Preeclampsia with Severe Features

• SBP ≥ 160 or DBP ≥ 110 on two occasions (confirmation

can occur over a short time frame to facilitate timely

antihypertensive therapy before 4 hrs)

• Proteinuria - ≥5 g in 24 hours or ≥3+ on dipstick on two occasions ≥ 4 hrs apart

• Oliguria - < 500 cc in 24 hrs

• Headache or visual disturbances

• Pulmonary edema

• Epigastric or RUQ pain unresponsive to medication

• Elevated liver enzymes (twice normal)

• Thrombocytopenia (<100,000)

• HELLP

• Fetal growth restriction

• Progressive renal insufficiency – Cr 1.1 mg/dl (new)

ACOG 2002, 2013

Prevention with Low Dose Aspirin

Therapy High Risk Factors Moderate Risk Factors

Begin Aspirin 81 mg

daily after 12 wks

If any are present If “several” are present

Hx of preeclampsia Nulliparity

Multiple gestation Obesity

Chronic HTN 1st degree relative with

history of preeclampsia

Pregestational DM African American or low

socioeconomic status

Renal disease ≥35 yrs old

Autoimmune disease Adverse pregnancy outcome

USPSTF, Annals of Internal Medicine, 2014

Therapeutic Goals

• Appropriately timed delivery

• Prevent eclampsia

• Acute control of blood pressure

– Goal is 140-159/90-109

Timing of Delivery

• At diagnosis after 37 wks for any

preeclampsia or gestational HTN

• At diagnosis after 34 wks if severe features

• Prior to 34 wks give corticosteroids and

individualize timing

Spong, NICHD 2011, ACOG 2013

Magnesium Sulfate

• Seizure prophylaxis during labor and

postpartum

– Not necessary in absence of severe

features

• Not an antihypertensive agent

– Causes transient decrease in BP in

hypertensive patients

– Does provide neuroprotection in the

preterm fetus <32 wks

Significance of Severe HTN in

Pregnancy or Postpartum

Acute-onset, persistent (lasting 15 min or more),

severe hypertension constitutes a hypertensive

emergency

Severe systolic hypertension may be the best

predictor of cerebral hemorrhage and infarction

and if not treated expeditiously can result in

maternal death.

ACOG Committee Opinions #514, 623, 692 from 2011, 2015, 2017

Morbidity Associated with

Severe Gestational HTN Outcome Severe

GHTN

(n=24)

Mild

Preeclampsia

(n=62)

Severe

Preeclampsia

(n=45)

RR

Mild preeclampsia

vs Severe GHTN

(95% CI)

RR

Severe preeclampsia

vs Severe GTHTN

(95% CI)

Birth wt

(g)

2637 3196 2490 - -

Delivery

<37 wks

54.2 16 66.7 2.10

(1.20-3.67)

0.81

(0.53-1.24)

SGA

(%)

20.8 4.8 11.4 4.31

(1.11-16.63)

1.83

(0.56-5.71)

Abruption

(%)

4.2 3.2 6.7 1.29

(0.12-13.59)

0.63

(0.07-5.69)

NICU

admission

(%)

24.2 20.8 38.1 0.86

(0.35-2.11)

0.55

(0.23-2.63)

Buchbinder, 2002

Acute Antihypertensive Dosing • Labetalol

– 20 mg 40 mg 80 mg 80mg

– Administer over 2 min

– Administer escalating dose every 10 min

– Maximum dose is 300 mg

• Nifedipine

– 10 mg 20 mg 20 mg

– Administer orally every 20 min up to total of 50 mg

• Hydralazine

– 10 mg

– Administer over 2 min

– Administer every 20 min

– Maximum dose is 30 mg

ACOG 2017

Comparative Effectiveness of Acute Therapy

Medication Pretreatment BP Met Treatment

Goal

Met Treatment Goal

OR

IV labetalol

(n=1057) 175/102 70.8 2.14

IV hydralazine

(n=611) 177/102 68.4 1.92

Oral Nifedipine

(n=38) 174/100 81.6 3.92

Oral Labetalol

(n=98) 175/102 53.1 1.00

Kilpatrick, AJOG 2016

Pharmacokinetics for Acute Therapy

Medication Onset of Action

(min)

Peak Effect

(min)

IV labetalol 2-5 5

IV hydralazine 5-20 15-30

Oral Nifedipine 5-20 30-60

Oral Labetalol 20-120 1-4 hours

CMQCC 2013

Pharmacokinetics for Oral Therapy

Medication Peak

Concentration

(hours)

Half Life

(hours)

Labetalol 1-4 6-8

Nifedipine XL 2.5-5 7

CMQCC 2013

Steady State Plasma

Concentration

NSAID’s & Severe Preeclampsia

Received

NSAID’s

(n=243)

Did not Receive

NSAID’s

(n=81)

Adjusted OR

(95% CI)

Persistent Severe HTN (%) 70 73 1.1

(0.6-2.0)

LOS (d) 4 4

Need for narcotics (%) 89 75 0.6

(.18-1.7)

HTN Readmission (%) 5 7 1.3

(0.4-4.5)

Viteri OB/Gyn, 2017

No difference in peak, average or discharge BP or type of antihypertensive used

based on whether NSAID’s were used or not.

Ibuprofen & Preeclampsia

Postpartum Parameter Ibuprofen

(n=50)

Acetaminophen

(n=50)

Time from Delivery to last BP >150/105 (hr) 58.3 57.1

Mean Maximum SBP 167.6 164.6

Mean Maximum DBP 99.2 96.4

Any BP>160/110 (%) 68 62

Any Acute Therapy (%) 60 52

Mean LOS (d) 3.8 4.0

Prolonged stay for BP Control (%) 36 46

Discharge on Antihypertensive (%) 66 62

Blue, Oral Abstract Presentation, SMFM 2018

Oral Antihypertensive Therapy • Following acute IV therapy

• Labetalol

– Stating dose 100 - 200 mg q 12 hrs

– May increase interval to q 8 hrs

– Maximum daily dose 2400 mg

– Half life 6-8 hrs

• Nifedipine as a 2nd agent

– Starting dose 30 mg XL daily

– May increase interval to q 12 hrs

– Maximum daily dose120 mg XL daily

– Half life 7 hrs SMFM, 2011

Contraception and Maternal Mortality

2008

Estimates

MM Ratio

(deaths/100,

000 live

births)

Contraceptive

Prevalence

Rate

(%)

Maternal

Deaths

(n)

Deaths Averted

by

Contraceptive

use (n)

Proportion of

deaths averted

by

contraceptive

use (%)

World 252 64.2 342,203 272,040 44.3

Developed

Regions

10 75 1038 1578 60.3

Developing

Regions

273 62.9 341,165 270,461 44.2

USA 13 78.2 574 887 60.8

Canada 7 77.5 24 36 60.7

UK 7 83.6 56 86 60.8

Sweden 4 80.6 5 8 60.8

Ahmed, Lancet, 2012

Contraception Eligibility Condition COC/P/R POP DMPA Implants LNG-IUD Cu-IUD

Postpartum

<21 days

3 1 1 1 2 2

Postpartum >21 days 1 1 1 1 1

(>4 wks)

1

(>4 wks)

Breast feeding <1 mo 3 2 2 2 2 2

Breastfeeding 1 mo-6 mo 2 1 1 1 1 1

HTN SBP140-159; DBP 90-99 3 1 2 1 1 1

HTN SBP >160; DBP >100 4 2 3 2 2 1

Category Description

1 No restriction for use

2 Advantages generally outweigh theoretical or proven risks

3 Theoretical or proven risks outweigh advantages

4 Unacceptable health risk CDC 2010

Barriers to proper treatment • Severe adverse outcomes are rare

• Side effects of therapy are readily apparent

• Normalization of deviance

• “She is in pain”

• “She is anxious”

• “She is asymptomatic”

• “The preeclampsia labs are normal”

• “Most of the BP’s are ok”

• “She only has gestational HTN”

• Nurse fails to notify provider “They don’t do

anything anyway”

Providence Efforts

• Raise awareness

– Educational programs, lectures, and data

presentations throughout the organization

• Standardize practice thinking about human

factors

– Adopt standard practices

– Standard order sets are in place

• Monitor and feedback at hospital and individual

provider level

– SMFM proposed quality measure

– Developed (semi) robust data abstraction capabilities

– Regular reports at regional and department meetings

Prevention & Improvement • Implement existing safety bundles

• Monitor and report outcomes

– Advocate for Oregon Maternal Mortality Review

Committee (MMRC) - one of 18 states without a one

• Legislature passed law on 3/2/18 establishing statewide MMRC!!

– Severe Maternal Morbidity rates

– Untreated Severe HTN with home grown EMR report

• Advocate for a reproductive life plan

– One key question – “Would you like to become pregnant

in the next year?”

– Engage primary care

• Increase awareness of health care team

• Utilize maternal levels of care

Standardized Practice

• System wide (Alaska to Southern CA)

work group

• Adapted CMQCC tool kit

– Standardized BP assessment

– Medication orders

– Postpartum duration of stay

Magnesium Orders

Acute Antihypertensive Orders

Work in Progress

• Educate and increase Emergency

Department awareness

• Exploring ways to improve patient

awareness and education

– Providence Circle App

• Evaluating severe HTN readmissions

and postpartum length of stay

• Reevaluation “ban” on NSAID’s

SMFM Proposed HTN Quality Measures

• Proportion of women with sustained severe

BP elevation receiving antihypertensive agent

within 30 min of continued BP elevation

• Low dose ASA for history of early or recurrent

preeclampsia

• Magnesium for preeclampsia with severe features

• Postpartum women with HTN disorder during

pregnancy who are transitioned to primary care and

educated on future risk of cardiovascular and

metabolic complications

Iriye, AJOG 2017

Conclusion

• Preeclampsia/Severe Gestational HTN

are common and associated with rare

but catastrophic complications

• With vigilance and aggressive

management in patients with severe

features, maternal and perinatal

adverse events can be minimized

• Progress is being made!!

QUESTIONS AND COMMENTS

Participants are encouraged to ask questions and share comments.

Please use the chat box for questions or comments.

Questions and comments are visible only to presenters.

Questions will be answered in the order in which they are submitted.

Should there not be enough time to address your question(s), please email education@npic.org so we may follow-up with you.

THANK YOU FOR ATTENDING

ATTENTION:

For 1.0 Contact Hour or

1.0 AMA PRA Category 1 Credit™

**DO NOT CLOSE YOUR BROWSER

WINDOW**

POST-TEST WILL AUTOMATICALLY APPEAR WHEN

THE WEBINAR HAS ENDED

Please complete the post-test within 24 hours

Certificates of Attendance & Completion will be emailed within 14 business days