pqcnc 2014 annual meeting elliott main

8/13/2019 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

2


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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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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.


M

aternalDeathsper100,0

00LiveBirths

7


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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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10,000)

ICU Admit(1-2 per

1,000)

Severe Morbid

(1-2 per100)


Infection 10% 5% 5%





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10,000)

ICU Admit(1-2 per

1,000)

Severe Morbid

(1-2 per100)


Infection 10% 5% 5%





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10,000)

ICU Admit(1-2 per

1,000)

Severe Morbid

(1-2 per100)


Infection 10% 5% 5%





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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

16


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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)

20


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122(4):735-736, October 2013

Editorial:

21


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CMMI: Center for Medicare &

Medicaid Innovation

22


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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

24


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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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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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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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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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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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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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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

stakeholder 33


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34

Everyones nightmare

34


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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
http://www.cmqcc.org/http://www.cmqcc.org/


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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

36
http://www.cmqcc.org/http://www.cmqcc.org/http://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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40

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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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

8

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).

18


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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.

15


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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?

24


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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.

26

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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50

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)

57

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

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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

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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

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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

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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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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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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.


MaternalDeathsper1

00,0

00LiveBirths

h k


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