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Telehealth for Postpartum HypertensionWAPC Annual Meeting

Kara Hoppe, DO

April 23rd, 2018

DisclosureI have no disclosures to report

Objectives• Epidemiology of pregnancy and postpartum

related hypertension• Historical prospective of hypertension throughout

pregnancy and postpartum

• Health care burden/cost of postpartum hypertension

• Treatment guidelines/options for hypertension postpartum

• Innovative strategies and experience with telehealth for treatment of postpartum hypertension at UnityPoint Health-Meriter

US-Hypertension disorders in pregnancy

� Almost 10% of pregnancies are affected by hypertension related disorders in the United States. 1

1. ACOG. Hypertension in Pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy.Obstet Gynecol. 2013;122(5):1122-1131.

Wisconsin- Hypertension in pregnancy

� Hypertensive disorders affect approximately 22% of pregnancies in Wisconsin. 2

1. Mogos MF, et al. Hypertensive disorders of pregnancy and postpartum readmission in the United States: national surveillance of the revolving door. Journal of Hypertension. 2017, 35: doi: 10.1097/HJH.00000000000015942. PeriData.Net®.

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Chronic hypertension in US

Whelton PK, 2017

Preeclampsia

� Incidence of preeclampsia has increased by 25% in the past 20 years

� Preeclampsia causes an estimated 60,000 maternal deaths yearly worldwide

� There are 50 –100 near misses for every maternal death

1. ACOG. Hypertension in Pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy.Obstet Gynecol. 2013;122(5):1122-1131.

Postpartum hypertension� Exact incidence is unknown

� Seventy-five percent of deaths secondary to gestational hypertensive disorders occur after birth, with 41% in one study occurring more than 48 hours postpartum.1

� Up to half of women eventually diagnosed with postpartum preeclampsia were not diagnosed with preeclampsia in the antepartum or immediate peripartum period.2

1. Zuleta-Tobón JJ, Pandales-Pérez H, Sánchez S, Vélez-Álvarez GA, Velásquez-Penagos JA. Errors in the treatment of hypertensive disorders of pregnancy and their impact on maternal mortality. Int J Gynaecol Obstet. 2013;121:78–81. 2. Yancey LM, Withers E, Bakes K, Abbott J. Postpartum preeclampsia: emergency department presentation and management. J Emerg Med. 2011;40:380–384

Risk of long-term cardiovascular disease

Powe, et al. Preeclampsia, a disease of the maternal endothelium. Circulation. 2011;123:2856-2869.https://doi.org/10.1161/CIRCULATIONAHA.109.853127

Historical perspectives: pregnancy & postpartum hypertension

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History of hypertensive disorders of pregnancy

� Late 5th and early 4th century BC-Hippocratics subscribed to theory of the four humors to describe illness and disease

� Women were considered wet while men were considered dry.� “Because a woman’s flesh was porous and soft, she was at risk of

drawing in too much moisture, resulting in an overabundance of fluids (humors) and subsequent illness.”

� 2000 BC-The Kahun Papyrus-Egypt� The wandering womb � References to eclampsia

� 400 BC-“A headache accompanied by heaviness and convulsionsduring pregnancy is considered bad” (Hippocrates).

History of hypertensive disorders of pregnancy

• 1500’s-Fallopius is credited with naming the placenta and indicating it was only found in the uterus during pregnancy.

Medical pioneers• 1619-”eclampsia” first appeared in Varandaeus’ treatise on

gynecology

• 1739-Bossier de Sauvages differentiated seizures of eclampsia from epilepsy

• 1840-Pierre Rayer discovered protein in the urine

• 1843-John Lever demonstrated proteinuria was specific to preeclampsia and not another kidney ailment -“toxemia”

• Mid 1800’s- hallmark prodromal symptoms of preeclampsia were recognized

Medical pioneers

• 1872- A survey found 25% of maternal deaths were due to eclampsia and doctors began to induce labor to “cure” preeclampsia

• 1896-Scipione Riva-Rocci’s mercury manometer for blood pressure measurement lead to recognition of preeclampsia as a hypertensive disorder

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Timeline: Diagnosis and treatment• Middle ages->1800’s blood-letting and opiates• 1906 –Horn was first to use magnesium sulfate to prevent

eclampsia• 1972 – 1st ACOG hypertension in pregnancy classification• 1987- Postpartum BP studies published• 1990-Controlled studies demonstrated superiority of

magnesium sulfate over other anticonvulsants to prevent eclampsia

• No major changes to prenatal care or diagnosis of preeclampsia since 1960’s

• 2013-Classification of hypertension in pregnancy updated by ACOG

Bell, et al. A historical overview of preeclampsia-eclampsia. J Obstet Gynecol Neonatal Nurs. 2010;39:510-518.

Hypertension in pregnancy initiatives

� National focus on Hypertension in Pregnancy/Readmission

� 2013 ACOG Executive Summary – Hypertension in Pregnancy

� California Collaborative- Preeclampsia taskforce (2014)

� Council on Patient Safety in Women’s Health Care

• AIM = Alliance for Innovation on Maternal Health

• Development and rollout of evidenced based patient safety bundles

• Severe Hypertension in Pregnancy Bundle (2015)

� WisPQC hypertension initiative (2015/16)1. ACOG. Hypertension in pregnancy.2. http://safehealthcareforeverywoman.org/patient-safety-bundles/severe-hypertension-in-pregnancy/. Accessed 4/10/18.3. https://www.cmqcc.org/resources-tool-kits/toolkits/preeclampsia-toolkit. Accessed 4/10/184. https://wispqc.org/initiatives/maternal-hypertension/. Accessed 4/10/18

Healthcare burden/costUS hospital readmission

US hospital readmission

1. Clapp, et al. A multi-state analysis of postpartum readmissions in the United States. AJOG. 2016;215:113.

#1

2015 post-partum readmissions Q1-3

#1

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Healthcare cost of postpartum readmission

� 2013-14

� 6.3 million delivery hospitalizations

� 10.6% complicated by hypertension diagnoses of pregnancy (HDP)

� HDP related hospital readmission ranged from 2.5-4.6%

� Compared with normotensive pregnancies, HDP resulted in an excess 404,800 hospital days and inpatient care costs of $731 million.

Mogos MF, Salemi JL, Spooner KK, McFarlin Bl, Salihu HH. Hypertensive disorders of pregnancy and postpartum readmission in the United States: national surveillance of the revolving door. Journal of Hypertension. doi: 10.1097/HJH.0000000000001594

Hospital readmission for CV event within 3 years of delivery

OBJECTIVE:Women with pregnancies complicated by hypertensive disorders of pregnancy (HDP) have increased long-term cardiovascular (CV) risk. We sought to determine if they demonstrate increased short-term CV risk.

• FLORIDA: 2004-2010• READMISSION WITHIN 3 YEARS OF INDEX DELIVERY• INCLUSION: GESTATIONAL HYPERTENSION, PREECLAMPSIA OR ECLAMPSIA• OUTCOMES: CV READMISSION (ACUTE MI, STROKE OR HEART FAILURE)• RESULTS:

• 1 452 926 records from delivering mothers of singleton infants (mean age 27.2±6.2 years; 52% white, 23% African American (AA), 18% Hispanic)

• 4054 CV and 259 252 non-CV readmissions. • Women with HDP had higher CV readmission rates (6.4 vs 2.5/1000 deliveries; P<0.001). AA women

had higher rates of CV readmission than whites or Hispanics (6.8 vs 1.7 vs 1.0/1000 deliveries, respectively; P<0.001). Women with HDP had higher multivariate risk of CV readmission (OR 2.41; 95% CI 2.08 to 2.80) and any readmission (OR 1.13; 95% CI 1.10 to 1.15). Compared with whites, AA women had higher risk for CV readmission (OR 3.60; 95% CI 3.32 to 3.90) after adjustment for HDP.

CONCLUSION:Women with HDP had twice the risk of CV readmission within 3 years of delivery, with higher rates among AA women. More work is needed to explore preventive strategies for HDP-associated events.

Jarvie JL, Metz TD, Davis MB, Ehrig JC, Kao DP. Short-term risk of cardiovascular readmission following a hypertensive disorder of pregnancy. Heart. 2018. doi: 10.1136/heartjnl-2017-312299.

Strategies to reduce avoidable maternal readmission

� During hospitalization:

� Risk screen patients and tailor care� Establish communication with PCP, family, home

care� Use “teach-back” to educate patient/caregiver about

diagnosis and care� Coordinate patient care across multidisciplinary

team

Source: AHA “Health Care Leader Action Guide to Reducing Avoidable Readmissions,” January 2010

Strategies to reduce avoidable maternal readmission

At discharge:

� Implement comprehensive discharge planning

� Educate patient/caregiver using “teach-back”• Blood pressure monitoring for hypertensive OB patients• Signs & symptoms of pre-eclampsia• Hand hygiene• Medications

� Schedule & prepare for follow-up appointment

Source: AHA “Health Care Leader Action Guide to Reducing Avoidable Readmissions,” January 2010

Discharge education

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Strategies to Reduce Avoidable Maternal Readmission

� Post-discharge� Promote self-management� Conduct patient home visit� Follow-up with patient via telephone

Source: AHA “Health Care Leader Action Guide to Reducing Avoidable Readmissions,” January 2010

Duration of hospital stay/follow-up: ACOG

� “For women in whom gestational hypertension, preeclampsia, or superimposed preeclampsia is diagnosed, it is suggested that BP be monitored in the hospital or that equivalent outpatient surveillance be performed for at least 72 hours postpartum and again 7-10 days after delivery or earlier in women with symptoms

Quality of evidence: Moderate

Postpartum hypertension: To treat or not to treat?

Postpartum hypertension� Can be related to persistence of….

� Gestational hypertension� Preeclampsia� Preexisting chronic hypertension� De novo secondary to other causes

Physiologic changes in pregnancy

Physiologic changes postpartum� Normotensive women had both SBP (6mmHg)

and DBP (4mmHg) that rose for the 1st 4 days after delivery.1

� 12% had DBP that was >100mmHg

� In women with preeclampsia there is a decrease in BP within 48 hours of delivery, but BP increases again between 3-6 days postpartum.2,3,4

1. Walters BN, Walters T. Blood pressure in the puerperium. Clin Sci (Lond). 1986 Nov;71(5):589-94.2. Walters BN, Walters T. Hypertension in the puerperium. Lancet 1987; 2:330.3. Peterson E, Craigo S, House M. Risk factors for postpartum antihypertensive mediation requirement in

severe preeclampsia. Hypertens Preganncy 2010;29:350-6.4. Ferrazzani S. De Carolis S, Pomini F, et al. The duration of hypertension in the puerperium of preeclamptic

women:relationship with renal impairment and week of delivery. Am J obstet Gynecol 1994;171(2):506-512.

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Walters,et al-1987

Walters BN, Walters T. Hypertension in the puerperium. Lancet 1987; 2:330.

Podymow, et al-2010� Objective: To determine the number of weeks

postpartum blood pressure normalized� Retrospective cohort study

� Gestational hypertension or preeclampsia (15-40wks GA)

� 62 women

� Results: If normalized, time to normalization was 5.4 + 3.7 weeks.� 19% remained hypertensive at 6 months

� 3 had a diagnosis of secondary hypertensionPodymow T, Aujgust P. Postpartum course of gestational hypertension and preeclampsia. Hypertens Pregnancy 2010;29:294-300.

What blood pressure values warrant treatment postpartum?

� The current ACOG guidelines are based upon expert opinion rather than experimental data and recommend treating postpartum hypertension at a systolic blood pressure (SBP) of >150 or diastolic blood pressure (DBP) of >100. 1-3

1.ACOG. Hypertension in Pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-1131.2.Podymow T, August P. Postpartum course of gestational hypertension and preeclampsia. Hypertens Pregnancy. 2010;29(3):294-300.3. Tan LK & deSweit. The management of postpartum hypertension. BJOG. Volume 109, Issue 7; 2002. 733–736

Tan & DeSweit, BJOG, 2002

The management of postpartum hypertension. Volume 109, Issue 7, July 2002. Pages 733–736.

Tan & DeSweit, BJOG, 2002� “

The management of postpartum hypertension. Volume 109, Issue 7, July 2002. Pages 733–736.

Timeline for hypertension follow-up?� Because maternal blood pressure has been shown to decrease

for the first 48 hours and then increase with a peak 3–6 days after birth for a woman with preeclampsia during the postpartum period, peak blood pressures are likely to occur after most women have been discharged home.

� Thus, checking maternal postpartum blood pressure within the first 7–10 days postpartum is recommended for women with preeclampsia or hypertensive disorders to determine whether there is a need for further evaluation and treatment.

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Evaluation and management of postpartum hypertension, Sibai 2012

Prevention and treatment of postpartum hypertension

• Objective-To assess the relative benefits and risks of interventions to:

• Prevent postpartum hypertension, by assessing whether “routine” postpartum medical therapy is better than placebo/no treatment

-and-

• Treat postpartum hypertension by assessing whether

• (i) one antihypertensive therapy is better than placebo/no therapy for mild-moderate postpartum hypertension; and

• (ii) one antihypertensive agent offers advantages over another for mild-moderate or severe postpartum hypertension.

Magee L. Prevention and treatment of postpartum hypertension. 2013

Results• Prevention

• 4 trials (358 women) compared furosemide, nifedipine, or L-arginine with placebo/no therapy.

• Women with antenatal preeclampsiaPostnatal furosemide is associated with a strong trend towards reduced use of antihypertensive therapy in hospital.

Results• Treatment

• Mild-moderate postpartum hypertension, 3 trials (189 women) compared timolol, hydralazine, or nifedipine, with methyldopa.

• Use of additional antihypertensive therapy did not differ between groups(RR 0.92, 95% CI 0.20-4.20)

• Drugs were tolerated

• Severe hypertension, 2 trials (120 women) compared hydralazine IV with nifedipine SL or labetalol IV.

• No maternal deaths or hypotension

• Use of additional antihypertensive therapy did not differ between groups(RR 0.58, 95% CI 0.04-9.07)

Conclusions• There are no reliable data to guide management of women

who are hypertensive postpartum.

• Any hypertensive agent used should be based on a clinician’s familiarity with the drug.

• Future studies should include data on postpartum analgesics, severe maternal hypertension, breastfeeding, hospital length of stay and maternal satisfaction with care.

Can we do better?

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Historical perspectives: Remote patient monitoring & telehealth

Telemedicine vs Telehealth• Telehealth and telemedicine are

sometimes used interchangeably

• Do they mean the same thing?

• Considerable debate

• Telemedicine:

• The clinical application of technology

• Telehealth:

• Encompasses a broader, consumer-facing approach- “a collection of means or methods, not a specific clinical service, to enhance care delivery and education.”

Telehealth applications defined• Live (synchronous) videoconferencing: a two-way

audiovisual link between a patient and a care provider

• Store-and-forward (asynchronous) videoconferencing: transmission of a recorded health history to a health practitioner, usually a specialist.

• Remote patient monitoring (RPM): the use of connected electronic tools to record personal health and medical data in one location for review by a provider in another location, usually at a different time.

• Mobile health (mHealth): health care and public health information provided through mobile devices. The information may include general educational information, targeted texts, and notifications about disease outbreaks.

Remote patient monitoring• The use of digital technologies to collect medical and other

forms of health data from individuals in one location and electronically transmit that information securely to health care providers in a different location for assessment and recommendations

• Vital signs: weight, blood pressure, blood oxygen levels, heart rate

• Electrocardiograms

• Blood sugar

• Benefits:

• Keep people healthy

• Reduce hospitalizations, readmissions and length of stay

• Improve quality of life

• Reduce healthcare costshttp://www.cchpca.org/remote-patient-monitoring. Accessed 4/3/2018

Remote patient monitoringTypes of blood pressure monitoring• Clinic

• Gold standard- mercury sphygmomanometers• Aneroid automatic

• Observed• Not observed

• Home• Self

• Ambulatory• 24 hour ambulatory

Drawz PE, et al. Blood pressure measurement:clinic, home, ambulatory and beyond. Am J Kidney Dis. 2012;60:449-462.

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Home blood pressure monitoring• Important to provide instruction and train

patients to standardize the process at home• A rest period prior to measurement• Appropriate position and cuff size• Avoidance of factors that influence blood

pressure

Welton PK, et al. 2017 High blood pressure clinical practice guideline: executive summary. Am College of Cardiology & Am Heart Association Taskforce on Clinical Practice Guidelines Drawz PE, et al. Blood pressure measurement:clinic, home, ambulatory and beyond. Am J Kidney Dis. 2012;60:449-462

Proper blood pressure cuff/monitor selection

**Use of the arm cuff is preferred compared to wrist and finger monitors

Welton PK, et al. 2017 High blood pressure clinical practice guideline: executive summary. Am College of Cardiology & Am Heart Association Taskforce on Clinical Practice Guidelines

Technique for HMBP monitoring

Welton PK, et al. 2017 High blood pressure clinical practice guideline: executive summary. Am College of Cardiology & Am Heart Association Taskforce on Clinical Practice Guidelines

BP values

++Tend to be lower at home

Welton PK, et al. 2017 High blood pressure clinical practice guideline: executive summary. Am College of Cardiology & Am Heart Association Taskforce on Clinical Practice Guidelines

Home blood pressure monitoring

� Home blood pressure monitoring has been demonstrated as a cost-effectiveness approach to hypertension treatment in non-obstetrical patients.7-8

� Preliminary research suggests home blood pressure monitoring in pregnancy 9,10,11 may also be effective.

7.. Stergiou GS, Bliziotis IA. Home blood pressure monitoring in the diagnosis and treatment of hypertension: a systematic review. Am J Hypertension. 2011;24(2):123-34.8. Hirshberg A. Telemedicine Platform Provides Convenient Way for Physicians to Manage Patients with Preeclampsia for Life-Threatening Complications. Poster presentation. American College of Obstetrics & Gynecology Clinical and Scientific Meeting in Washington, DC. May 20169. Taylor RS, et al.. Evaluation of ambulatory and self-initiated blood pressure monitors by pregnant and postpartum women.. Hypertens Pregnancy. 2001;20(1):25-33.10. Magee LA, et al. Women's views of their experiences in the CHIPS (Control of Hypertension in Pregnancy Study) Pilot Trial. Hypertens Pregnancy. 2007;26(4):371-87. 11. Brown MA. Is there a role for ambulatory blood pressure monitoring in pregnancy? Clin Exp Pharmacol Physiol. 2014 Jan;41(1):16-21. doi: 10.1111/1440-1681.12106.

Remote patient monitoring for postpartum hypertension

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Objective

� To establish the feasibility of telehealth for monitoring and treatment of postpartum women at risk of sustained or development of severe hypertension (SBP>150 or DBP>100 mmHg) within 6 weeks after discharge.

� Primary outcomes

� Recruitment� Retention

� Secondary outcomes

� Incidence of severe hypertension after hospital discharge, patient satisfaction, and hospital readmission rates.

Hypothesis

� Our telehealth intervention will be implemented

with strong fidelity, have positive patient

acceptability, and demonstrate a meaningful

reduction in home blood pressures and

postpartum hospital readmission.

Recruitment 3/2017- /2017� 1414 deliveries

� 263 (19%) had a hypertension diagnosis� 124 ( 47%) were willing to be approached

• 55 ( 44.4%) consented

Preliminary dataTable 1. Maternal Demographic Characteristics

Total Population n=55Maternal age in years, m (SD) 32 (4.9)Married, n (%) 45 (82)Parity, Nulliparous, n (%) 34 (62)Race, White, n (%) 51 (93)Ethnicity, Hispanic, n (%) 5 (9.1)Current tobacco use, n (%) 4 (7.3)Gestational age at delivery in weeks, m (SD) 37 (3.1)Mode of Delivery

Vaginal, spontaneous or operative, n (%) 23 (42)Cesarean, n (%) 32 (58)

Neonatal intensive care unit admission, n (%) 16 (29)Type of Hypertension

Chronic, n (%) 6 (11)Superimposed preeclampsia 3 (5.5)

Gestational, n (%) 15 (27)Preeclampsia, n (%) 34 (62)

Severe features 17 (31)Inpatient NSAID use, n (%) 47 (85)Postpartum day of discharge, m (SD) 3.2 (1.0)Hospital discharge systolic blood pressure mmHg, m (SD) 134 (11)Hospital discharge diastolic blood pressure mmHg, m (SD) 77 (8.9)Antihypertensive medication at discharge, n (%) 22 (40)Labetalol, n (%) 12 (55)Nifedipine, n (%) 4 (18)Labetalol & Nifedipine, n (%) 6 (27)n, number; %, percent; m, mean; SD, standard deviation; NSAID, non-steroidal anti-inflammatory drugs; mmHg, millimeters Mercury

Table 2. Outpartient outcomes of participants experiencing severe hypertension after hospital discharge

Total Population n=55

Severe hypertension after discharge*, n (%) 7(12.7)

Postpartum day severe hypertension occurred, m (SD) 3.7 (0.76)

Systolic blood pressure mmHg, m (SD)

Diastolic blood pressure mmHg, m (SD)

Total participants with increased blood pressure requiring treatment after discharge, n (%)** 22(40)

1st Postpartum day blood pressure required treatment after discharge**,m (SD) 5(2.0)

Systolic blood pressure mmHg, m (SD) 153 (9.8)

Diastolic blood pressure mmHg, m (SD) 101 (9.7)

Total participants requiring antihypertensive medication over 42 days postpartum period, n (%) 33 (60)

Initiated a hypertensive medication after discharge, n (%) 11 (20)

Increased dosage of medications, n (%) 13 (24)

Total participants on antihypertensive medication at end of study, n (%)

Emergency/triage room visit, n (%) 6 (11)

Hospital readmission, n (%) 0 (0)

n, number; %, percent; m, mean; SD, standard deviation; NSAID, non-steroidal anti-inflammatory drugs; mmHg, millimeters Mercury*Severe hypertension defined using ACOG criteria in pregnancy: >160 mm Hg or >110 mm Hg**Blood pressure requiring postpartum treatment defined using ACOG recommendations of >150 mm Hg or >100 mm Hg

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How satisfied were you with your telehealth experience?

To what extent would you prefer using telehealth vs the clinic amongst

postpartum women with hypertension related diagnosis and using telehealth?

Feasibility project: Summary� N=55 patients

� Recruitment: � Consented: 44.4%

� Retention: 95%� Hospital readmission:0%

� Patient satisfaction: 86% (very or extremely)� Total participants with increased blood pressure

requiring treatment after discharge: 40%

� Severe hypertension after hospital discharge: 13%� Postpartum day severe hypertension occurred,

mean(SD): 3.7(0.76)

Limitations

� Single site Midwestern academic institution

� Small sample size� Limited ethnic/racial diversity

Conclusions: perspective and clinical relevance

� We demonstrated feasibility of telehealth monitoring for postpartum hypertension-related disorders.

� We observed important temporal trends in the natural history of postpartum hypertension from discharge through 6 weeks postpartum which will guide larger clinical trials.

� Telehealth monitoring is a promising outpatient treatment strategy for postpartum hypertension to reduce readmissions and decrease maternal morbidity.

Future directions� Understanding natural time course of postpartum

hypertension through 6 weeks and beyond.� Comparing outcomes in remote patient monitoring

vs. standard of care. (Current work)

� Analyzing predictors of adverse outcomes and optimal blood pressure treatment postpartum.

� Cost effectiveness analysis

� Increased transition of care to a PCP for women with persistent of chronic hypertension after the postpartum period

� Increased education on importance of long-term BP control.

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Summary� Surveillance- We can do better! Remote patient

monitoring may be an answer.� Treatment- We should feel good about using

antihypertensive medications- safe and effective.

� Pain medication-NSAIDS are unlikely to routinely be the cause hypertension exacerbation

� Persistent hypertension-We can improve strategies to improve follow-up and CV screening after 6 weeks postpartum.

AcknowledgementsCollaborators: Makeba Williams, MDOguzhan Alagoz, PhD

Resident/student research investigators:Brenda Niu, MDAnna Drewry, MDBarbara Ha, MD,MPH

Research team:Jennifer Heintz, MBAJulia Zella, PhDMelissa Zernick, BS

Research/Telehealth nurses:Kris Fedenia, RNNicole Thomas, RN

Perinatal Nurse Manager:SueEllen Dolan, RN

Maternal Fetal Medicine Division

Provider groups:UW OB/GYNUW MidwivesAssociated PhysiciansMadison Women’s HealthPhysician for Women

Mentors:Deb Ehrenthal, MD,MPH Heather Johnson, MD,MSEllen Hartenbach, MDKyungmann Kim, PhDChris Sorkness, PhD

Honeywell:Linda Moore,RNDiane Yetmar, BS

UW Institute for Clinical and translational research

What is role for magnesium sulfate postpartum?

• Frequency of eclampsia in women with preeclampsia without severe features was 1.6 percent without prophylaxis versus 0.7 percent with prophylaxis.1

• 21% of eclamptic seizures occur postpartum. 2

• Approximately 90 percent of postpartum seizures occur within one week of delivery.3

• Antecedent symptoms were similar to those with antepartum and intrapartum eclampsia. • Most commonly a headache

1. Altman D, Carroli G, Duley L, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002; 359:1877.

2. Duley L, Matar HE, Almerie MQ, Hall DR Alternative magnesium sulphate regimens for women with pre-eclampsia and eclampsia.Cochrane Database Syst Rev. 2010

3. Al-Safi Z, Imudia AN, Filetti LC, et al. Delayed postpartum preeclampsia and eclampsia: demographics, clinical course, and complications. Obstet Gynecol 2011; 118:1102.

Duration of postpartum magnesium therapy?

• Typically continued for 24 hours postpartum, however the timing of drug discontinuation has been arbitrary; there are no high-quality data to guide therapy. 1

• In most women who have preeclampsia without severe features, therapy can be safely discontinued after 12 hours.2

1. Berhan Y, Berhan A . Should magnesium sulfate be administered to women with mild pre-eclampsia? A systematic review of published reports on eclampsia. J Obstet Gynaecol Res. 2015;41(6):831. Epub 2015 Apr 1.

2.Ehrenberg HM, Mercer BM. Abbreviated postpartum magnesium sulfate therapy for women with mild preeclampsia: a randomized controlled trial. Obstet Gynecol. 2006;108(4):833.

Postpartum magnesium sulfate: RCTSMFM abstract. Ludmir, et al.

Objective: To determine if the use of magnesium sulfate post delivery reduces the risk of eclampsia postpartum in patient s with severe preeclampsia that 8g of magnesium prior to delivery

Methods: RCT, Latin America

Non-inferiority design– 1113 patientsStudy arms: magnesium for 24 hours or no magnesium

Primary Outcome: Development of eclampsia within 24 hours postpartum.

Conclusion:

• In patients who received 8g of magnesium prior to delivery-24 hours of postpartum magnesium was not associated with a reduction in eclampsia. (p-value. 0.99).

• Time to ambulation and lactation were significanty decreased in those who did not receive magnesium (p-value, 0.0001)

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Magnesium sulfate postpartum• For women in the postpartum period with new-

onset hypertension associated with headache, vision changes or preeclampsia with severe features parental administration of magnesium sulfate is suggested

Quality of evidence: Low

Is it safe to take antihypertensive medication and breastfeed?

1. Podymow T, August P. Antihypertensive drugs in pregnancy. Semin Nephrol 2011;31:70-85.2. Beardmore, et al. Excretion of antihypertensive medication into human breast milk: a systematic review.

Antihypertensive medication postpartum

Lactation and antihypertensive medsConclusion: The available data to date indicate that

ACE inhibitors, methyldopa, beta-blockers with high protein binding and some calcium channel blockers all appear to be safe treatments of hypertension in a nursing mother.

**Methyldopa has been associated with increasing postpartum depression.

Beardmore, et al

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What about NSAIDS?� Causes vasoconstriction, sodium and water

retention.� Use of large or frequent doses may aggravate

preexisting hypertension or result in new-onset hypertension.

The Task Force on Hypertension-ACOG, 2013

� “Health care providers are reminded of the contribution of nonsteroidal anti-inflammatory agents to increased blood pressure. It is suggested that these commonly used postpartum pain relief agents be replaced by other analgesics in women with hypertension that persists more than 1 day postpartum.”

SMFM abstract-Viteri, 2017 � Single center, 2013-2015

� Retrospective analysis of 324 women with preeclampsia with severe features diagnosed prior to delivery and SBP >140 and/or DBP>90 at or 24 after delivery.

� 243 (75%) received puerperal NSAID treatment � Primary endpoint: persistent hypertension (SBP

>150 and/or DBP> 100.� 70% using NSAIDS � 73% no NSAIDS

� Conclusion: No statistical difference in primary outcome

To treat or not to treat- conclusion� There is lack of understanding regarding the natural

course of postpartum hypertension.� There is considerable uncertainty regarding the

need for antihypertensive treatment postpartum, due to the concern that patients may be unnecessarily treated if the BP normalizes and thus the management as well as patient counseling has been unguided by the literature.

� The duration of magnesium sulfate remains debatable.

� Antihypertensive medications are compatible with breastfeeding.

� Little evidence to routinely withhold NSAIDS postpartum.

Hypertension Definitions ACOG Executive Summary-Hypertension Classification

� 2013 Updates� 4 main hypertension classifications

• Preeclampsia-eclampsia• Chronic hypertension• Chronic hypertension with superimposed preeclampsia• Gestational hypertension

** Removed pregnancy induced hypertension and mild preeclampsia***

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ACOG Executive Summary-Modifications

� Eliminated the dependence of proteinuria to diagnose preeclampsia. � Without proteinuria, preeclampsia is diagnosed as

hypertension in association with thrombocytopenia, impaired liver function, or new renal insufficiency, pulmonary edema, a new-onset cerebral or visual disturbance.

� Gestational hypertension is BP elevation >20 weeks of gestation and absence of proteinuria.

� Chronic hypertension predates pregnancy� Superimposed preeclampsia is chronic in

association with preeclampsia

Chronic hypertension defined

Whelton PK, 2017

� The aim of this initiative is to increase the number of providers (defined as hospitals or health systems) who use evidence-based protocols for screening and managing women with hypertension in the antepartum, intrapartum, and postpartum period.

� WisPQC accomplished this aim through the 2015 Regional Forum Series.

2015: Maternal hypertension initiative2016

� Cohort I (2016) focused on 4 quality measures:

� Maternal length of stay*� Consumer education*

� NICU admission/transfer� Provider education

2016� Cohort II (2016) focused on 7 quality measures:

� Maternal length of stay*� Consumer education*

� NICU admission/transfer� Low-dose aspirin with maternal risk factors

� Appropriate medical management in less than 60 minutes*

� Debriefs for severe range hypertension� Severe maternal morbidity

Maternal hypertension initiative� Data from this initiative can inform future policies, practices and quality

improvement/research initiatives

� Policy� Implementation of ACOG and USPSTF recommendations have the

potential to• Promptly identify maternal HTN• Provide appropriate treatment

• Provide vigilant and continuing care postpartum � subsequent pregnancies

� Practice� Changes provide the potential to impact maternal and newborn care

� QI/research� Ease of access and availability of PeriData.Net® reports for hospitals make

these efforts possible� Opportunities to increase capacity?

4/20/2018

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How is WI doing after WisPQC initiative?� Postpartum length of stay

� Any hypertension (excluding chronic): Minimal hospital stay of 72 hours was achieved for 38% of women, only 13% amongst vaginal deliveries.

� Preeclampsia with severe features + VD: 39%� Superimposed preeclampsia with severe features +

VD: 63%

� Management of severe hypertension (hypertensive emergencies)

� Severe maternal morbidity

Goals of treatment for chronic hypertension

Blood Pressure Profile 1 Year After Severe Preeclampsia Novelty and Significance

Benschop L, et al. Blood Pressure Profile 1 Year After Severe Preeclampsia Novelty and Significance. Hypertension. 2018;71:491-498.