Challenges in the Diagnosis of Preeclampsia

Arthur Ollendorff, MD C-MOP/PQCNC Webinar February 11, 2014

Objectives
!! To

develop a process to identify and assess the subjective symptoms that define severe disease !! To identify opportunities and best practices to accurately measure blood pressure !! To identify strategies to help providers properly categorize women with hypertension in pregnancy

Common Things Happen Commonly

!! Last

shift of my night float week

patients

"! Antepartum

! 33 weeks with superimposed preE ! 30 weeks rule-out preE

"! 3

postpartum patients

! POD#3 32 week twins atypical HELLP ! POD#0 35 weeks chronic HTN, failed CST ! PPD#0 33 weeks, preE with severe features

Severe Features of Preeclampsia

!!

!! !!

!! !! !!

Systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher Thrombocytopenia Impaired liver function "! LFTs "! severe persistent right upper quadrant or epigastric pain Progressive renal insufficiency Pulmonary edema New-onset cerebral or visual disturbances
Hypertension In Pregnancy (2013). ACOG Hypertension In Pregnancy Taskforce.

ACOGs Guidance
!! Right

upper quadrant/epigastric pain

"! Severe

and persistent "! Unresponsive to medication "! Not accounted for by alternative diagnoses
!! Cerebral/visual "! Document

disturbances

inconsistently mentions new-onset and persistent

Hypertension In Pregnancy (2013). ACOG Hypertension In Pregnancy Taskforce.

Approach to RUQ/Epigastric Pain

!! Differential
"!

diagnosis
disease

GERD

"! Gallbladder "! Gas

pains "! Liver capsular swelling

!! What
"! GI

are reasonable interventions?

cocktail, PPI "! Patience

Cerebral and Visual Disturbances

!! Differential "! Tension

diagnosis

headache "! Migraine headache "! Hypertensive crisis "! Subarachnoid hemorrhage
!! What

are reasonable interventions

or narcotics?

"! Tylenol "! Fioricet

Opportunity for Quality Improvement

!!

Developing an institutional approach to the subjective symptoms of preeclampsia

Blood Pressure

We All Have Heard This

!! When

I have a high BP on the machine I will do a manual BP !! Take her BP again and if its normal then you are fine !! That BP doesnt count because she was ______ [nervous, having a contraction, just had a cigarette]

Suggested BP Measurement
!! Optimal

blood pressure is measured

"! Patient

comfortably seated "! Legs uncrossed "! Middle of blood pressure cuff on upper arm is at level of right atrium "! Patient should relax and not talk "! Ideally 5 minutes should pass before the first BP measurement is taken
Hypertension In Pregnancy (2013). ACOG Hypertension In Pregnancy Taskforce. P. 17

What we actually do
!! Blood

pressures taken on the upper arm with the patient in the left lateral position can falsely lower blood pressure !! This approach should be discouraged

Hypertension In Pregnancy (2013). ACOG Hypertension In Pregnancy Taskforce. P. 17

CMQCC Approach
1.! 2.! 3.! 4.!

Prepare equipment Prepare the patient Take measurement Record measurement

CMQCC Preeclampsia Toolkit. P. 26

Equipment: Proper Cuff Size

! Correct size cuff ! width of bladder 40% of circumference and encircle 80% of arm

CMQCC Preeclampsia Toolkit. P. 27

Take Measurement
!! Support

patients arm at heart level, seated in semi-fowlers position !! Instruct the patient not to talk !! At least one additional reading should be taken within 15 minutes
"! Use !! Do

the highest reading

not reposition patient to either side to obtain a lower BP. This will give you a false reading
CMQCC Preeclampsia Toolkit. P. 26

Opportunity for Quality Improvement

!! Developing

a standard process of how to measure and document BP at your institution

"! What

is the utility of cycled, unmonitored BP measurements? "! Are BPs that the nurse knows is not accurately measured included in chart? "! How to properly monitor BP on laboring patients?

Case Study
CC is a 17 year who presented to her local health center to establish prenatal care. She was found to have a 32+ week IUP and a BP 185/114. She was given labetolol and sent to her local hospital for evaluation. There her BP was 175/112, she was given hydralazine and sent to the regional referral OB hospital.

Case Study
After transfer to the hospital she was placed on MgSO4 for 48 hours and given a course of antenatal corticosteroids. Blood pressure normalized. AST and platelets were normal. No severe symptoms. 24 hour urine protein was 3700 mg.

Case Study
Her BP acutely worsened on the third hospital day and her labor was induced. Three hours later she delivered a male infant weighing 1880 gm. Newborn is in NICU on room air.

Case Study
!! What

is the patients hypertension diagnosis? !! Were there opportunities for improvement in the patients care?

C-MOP Participating Sites

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

Cape Fear Valley Caromont Cleveland Regional CMC-Main CMC-Northeast CMC-Pineville Columbus Duke Forsyth Granville

McDowell Mission New Hanover Novant-Huntersville Presbyterian Rex Transylvania UNC Vidant Wake Med Womack

February 4, 2014

References
Hypertension In Pregnancy (2013). ACOG Hypertension In Pregnancy Taskforce Maurice L. Druzin, MD; Laurence E. Shields, MD; Nancy L. Peterson, RNC, PNNP, MSN; Valerie Cape, BSBA. Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care). California Maternal Quality Care Collaborative, November 2013.