PQCNC Challenges in the Diagnosis of Preeclampsia

8/13/2019 PQCNC Challenges in the Diagnosis of Preeclampsia

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Challenges in theDiagnosis of

Preeclampsia Arthur Ollendorff, MD

C-MOP/PQCNC WebinarFebruary 11, 2014


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Objectives

! To develop a process to identify andassess the subjective symptoms that

define severe disease! To identify opportunities and best

practices to accurately measure bloodpressure

! To identify strategies to help providersproperly categorize women withhypertension in pregnancy


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Common Things HappenCommonly! Last shift of my night float week

" Antepartum patients

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


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Severe Features of Preeclampsia

! Systolic blood pressure of 160 mm Hg or higher, ordiastolic 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 PregnancyTaskforce.


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ACOGs Guidance

! Right upper quadrant/epigastric pain" Severe and persistent" Unresponsive to medication" Not accounted for by alternative

diagnoses

! Cerebral/visual disturbances" Document inconsistently mentions

new-onset and persistent

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


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Approach to RUQ/EpigastricPain

! Differential diagnosis" GERD

" Gallbladder disease" Gas pains" Liver capsular swelling

! What are reasonable interventions?" GI cocktail, PPI" Patience


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Cerebral and VisualDisturbances! Differential diagnosis

" Tension headache" Migraine headache" Hypertensive crisis" Subarachnoid hemorrhage

! What are reasonable interventions" Tylenol" Fioricet or narcotics?


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Opportunity for QualityImprovement! Developing an

institutional

approach to thesubjectivesymptoms ofpreeclampsia


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Blood Pressure


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We All Have Heard This

! When I have a high BP on themachine I will do a manual BP

! Take her BP again and if its normalthen you are fine

! That BP doesnt count because she

was ______ [nervous, having acontraction, just had a cigarette]


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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 PregnancyTaskforce. P. 17


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What we actually do

! Blood pressures taken on the upperarm with the patient in the left lateral

position can falsely lower bloodpressure! This approach should be

discouraged

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


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CMQCC Approach

1. Prepare equipment2. Prepare the patient3. Take measurement4. Record measurement

CMQCC Preeclampsia Toolkit. P. 26


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Equipment: Proper Cuff Size

CMQCC Preeclampsia Toolkit. P. 27

Correct size cuff width of bladder 40% of circumference

and encircle 80% of arm


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Opportunity for QualityImprovement! 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 inchart?

" How to properly monitor BP on

laboring patients?


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Case Study

CC is a 17 year who presented to herlocal health center to establish prenatal

care. She was found to have a 32+week IUP and a BP 185/114. She wasgiven labetolol and sent to her localhospital for evaluation. There her BPwas 175/112, she was givenhydralazine and sent to the regionalreferral OB hospital.


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Case Study

After transfer to the hospital she wasplaced on MgSO4 for 48 hours and

given a course of antenatalcorticosteroids. Blood pressurenormalized. AST and platelets werenormal. No severe symptoms. 24 hoururine protein was 3700 mg.


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Case Study

Her BP acutely worsened on the thirdhospital day and her labor was induced.

Three hours later she delivered a maleinfant weighing 1880 gm. Newborn is inNICU on room air.


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Case Study

! What is the patients hypertensiondiagnosis?

! Were there opportunities forimprovement in the patients care?


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C-MOP Participating Sites

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Cape Fear ValleyCaromontCleveland RegionalCMC-MainCMC-NortheastCMC-PinevilleColumbusDukeForsythGranville

McDowellMissionNew HanoverNovant-HuntersvillePresbyterianRexTransylvaniaUNCVidantWake MedWomack

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February 4, 2014

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References

Hypertension In Pregnancy (2013). ACOG Hypertension InPregnancy Taskforce

Maurice L. Druzin, MD; Laurence E. Shields, MD; Nancy L.Peterson, RNC, PNNP, MSN; Valerie Cape, BSBA.Preeclampsia Toolkit: Improving Health Care Response toPreeclampsia (California Maternal Quality CareCollaborative Toolkit to Transform Maternity Care).California Maternal Quality Care Collaborative, November2013.

PQCNC Challenges in the Diagnosis of Preeclampsia

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