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Extreme Complications in High Risk Obstetrics

Carol J Harvey, MS, RNC-OB, C- EFM, CS Clinical Nurse Specialist

Women’s Services Northside Hospital

Atlanta – Cherokee – Forsyth Georgia

In Memory of My Mother,

Mildred Harvey, MSN, BSN, RNC-OB

Clinical Resources

www.carolharvey.com

Select: AWHONN 2014 Handouts

Download Resources

Pregnancy Challenges in the 21st Century

1.  Challenging Pregnant Patients A.  Changing OB Population B.  Changing Care Delivery System

a.  Barriers-Access b.  Lack/Loss of Regionalization

Diseases/Complications Increasing in Pregnancy

1.  Preeclampsia-Eclampsia

2.  Chronic Hypertension

3.  Stroke and other Neurologic Complications

4.  Cardiac Complications

5.  Hemorrhage

6.  Renal Disease 7.  Pulmonary

Embolism, Asthma, Pulmonary Edema

8.  Hematologic complications

9.  Immunologic 10.  Others

The Power of Diagnostic Algorithms

❖ History, history, history ◆ Best practice at the bedside

❖ Physical exam ❖ Interpreting laboratory studies ❖ Auto “Triggers” for additional testing/

investigations ❖ Data-initiated “Consults”

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Case Studies

“Magpie” Study

MAGnesium Sulphate for Prevention of Eclampsia ❖ THE LANCET • Vol 359 • June 1, 2002

“Magpie” Study

❖ 10,141 women, antepartum or <=24 hours postpartum ❖ Blood pressure of 140/90 mmHg or more ❖ Proteinuria of 1+ (30 mg/dl) or more ❖ Included women in 33 countries ❖ Magnesium sulphate (n=5071), placebo

(n=5070).

MAGPIE: 10,141 women were randomized at 175 secondary and tertiary level hospitals in 33 countries

❖  Low perinatal mortality ◆  Albania ◆  Australia, ◆  Canada, ◆  Cuba, ◆  Denmark, ◆  Israel, ◆  Italy, ◆  Singapore, ◆  The

Netherlands, ◆  UK, and ◆  USA

❖  Mod perinatal mortality ◆  Argentina, ◆  Colombia, ◆  Jordan, ◆  Malaysia, ◆  Mexico, ◆  Sri Lanka, ◆  Thailand, ◆  United Arab

Emirates, ◆  Venezuela, and ◆  Zimbabwe.

❖  High perinatal mortality ◆  Bangladesh ◆  Brazil, ◆  Egypt, ◆  Ghana, ◆  India, ◆  Malawi, ◆  Nigeria, ◆  Pakistan, ◆  Sierra Leone, ◆  South Africa, ◆  Uganda, and ◆  Yemen.

“Magpie” Study

❖ Women allocated magnesium sulphate had a 58% lower risk of eclampsia ◆ 11 fewer women with eclampsia per 1000

women

❖ Maternal mortality was lower among women allocated magnesium sulphate ❖ No substantive harmful effects to mother

or baby in the short term were identified

Findings:

Post – “Magpie” Trial

❖ The lower risk of eclampsia following prophylaxis with magnesium sulphate was NOT associated with a clear difference in the risk of death or disability for children at 18 months.

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Post – “Magpie” Trial

❖ The reduction in the risk of eclampsia following prophylaxis with magnesium sulphate was not associated with an excess of death or disability for the women after 2 years

Magnesium Sulfate

. LANCET Volume 345, June 10, 1995. Multinational Trial to Measure Maternal and Neonatal Outcomes after Administration of Select Anticonvulsant Drugs. (Primary Investigator L. Duley – same in MAGpie trial)

Magnesium Sulfate

❖ Magnesium sulfate superior to placebo

❖ Magnesium sulfate superior to Phenytoin (Dilantin, Prompt, Di-Phen)

❖ Magnesium sulfate superior to other anti-seizure medications

LANCET Volume 345, June 10, 1995.

What type of IV solutions are considered “best practice” for this patient for initial stabilization?

A.  Lactated Ringers (Plain LR) B.  D5LR

C.  0.9%NaCl

D.  0.24%NaCl

A.  Lactated Ringers (Plain LR) B.  D5LR

C.  0.9%NaCl

D.  0.24%NaCl

What type of IV solutions are considered “best practice” for this patient for initial stabilization?

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?

Hydralazine 10 mg IV

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

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.

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

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❖  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

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 pre- eclampsia or eclampsia. Committee Opinion No. 514. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118: 1465–8

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?

Hydralazine 10 mg IV

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

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.

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

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

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

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.

Starting Dose and Titration

❖ Non-pregnant patient: ◆ Starting dose 3 to 5 mg/hour ◆ Increase rate by 2.5 mg/hour every 5 minutes

to a maximum of 15 mg/hour ❖ Pregnancy ◆ Starting dose 1 to 3 mg/hour ◆ Increase by 0.5 to 1.0 mg/hour to maximum of

10 mg/hour until the target BP is reached

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

Maternal and fetal/neo adverse effects of intravenous nicardipine in 147 patients

Maternal Transient hypotension

8

Nausea 3 Palpitations 3 Headache 11 Flushing 8

Fetal/Neonatal Bradycardia 0 Decelerations 2 Loss of variability 1 Preterm delivery 59 Small for gestational age

24

Apgar score <7 after 5 mins

3

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

Non-responders: Sodium Nitroprusside (Nipride®)

“When Nothing Works . . .” ❖ Sodium nitroprusside should be reserved for extreme emergencies and used for the shortest amount of time possible. ❖ Rationale/side effects: ❖ Cyanide and thiocyanate toxicity in the

mother and fetus or newborn (monitor maternal levels during administration) ❖ Increased intracranial pressure with potential

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

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 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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Clinical Resources

www.carolharvey.com

Select: AWHONN 2014 Handouts

Download Resources

Summary