Maternal Safety Bundle for Severe Hypertension in Pregnancy

Maternal Safety Bundle for Severe Hypertension in Pregnancy

Severe Hypertension in Pregnancy: Key Elements
Risk Assessment & Prevention Diagnostic Criteria When to Treat Agents to Use Monitoring Readiness & Response Complications and Escalation Process Further Evaluation Change of Status Postpartum Surveillance The “Key Elements” outlined here provide an overview of the components of the severe hypertension in pregnancy bundle. For information on how to further implement and incorporate this bundle within the obstetric unit, please refer to the introductory section of this toolkit for an overview of important clinical considerations.

Diagnostic Criteria: Severe Hypertension
Severe hypertension that is accurately measured using standard techniques and is persistent for > 15 minutes is considered a hypertensive emergency. Severe hypertension can occur during the antepartum, intrapartum, or postpartum period. Severe hypertension is defined as: systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 110 mm Hg Severe hypertension is defined as a systolic BP ≥ 160 or a diastolic BP ≥ 110. Accurately measured using standard techniques, severe hypertension that persists for > 15 minutes is considered a hypertensive emergency. This can occur during the antepartum, intrapartum, or postpartum period in women not known to have chronic hypertension, who develop sudden, severe hypertension due to preeclampsia/eclampsia or gestational hypertension, or in women with chronic hypertension who develop superimposed preeclampsia with acutely worsening or difficult to control, severe hypertension.

When to Treat: Metrics All pregnant or postpartum patients with systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 110 mm Hg that persists > 15 minutes require treatment. Regardless of when a patient presents with severe hypertension, ALL pregnant or postpartum patients with a systolic BP ≥ 160 or a diastolic BP ≥ 110 that persists beyond 15 minutes require treatment. Remember, this represents a hypertensive emergency and prompt treatment may be life-saving.

Agents to Use: First Line
First line medications for the management of severe hypertension in pregnant and postpartum women are: Intravenous labetalol Intravenous hydralazine Note: Magnesium Sulfate Is not recommended as an antihypertensive agent Remains the drug of choice for seizure prophylaxis and for controlling seizures in eclampsia Unless contraindicated, should be given when managing a hypertensive crisis IV bolus of 4-6 grams in 100 ml over 20 minutes followed by IV infusion of 1-2 grams per hour continue for 24 hours postpartum As most practitioners know, the first line agents for managing a hypertensive crisis in pregnancy are intravenous labetalol and intravenous hydralazine. While magnesium sulfate may be associated with a small drop in BP, it is important to remember that it is not recommended as an antihypertensive medication. However, magnesium sulfate is the drug of choice for seizure prophylaxis in women with preeclampsia and for controlling seizures in cases of eclampsia. Therefore, unless contraindicated, magnesium sulfate should be given when managing a hypertensive crisis for all pregnant patients > 20 weeks and all postpartum patients. This includes an intravenous bolus of 4 to 6 grams over 20 minutes followed by an infusion of 1 to 2 grams per hour which should be continued for 24 hours postpartum.

Algorithm: First Line Management with Labetalol*
SBP ≥ 160 or DBP ≥ 110 Notify a provider and institute fetal surveillance if viable Labetalol 20 mg IV over 2 minutes Repeat BP in 10 minutes If SBP ≥ 160 or DBP ≥ 110, administer labetalol 40 mg IV over 2 minutes; if BP is below threshold, continue to monitor BP closely Repeat BP in 10 minutes If SBP ≥ 160 or DBP ≥ 110, administer labetalol 80 mg IV over 2 minutes; if BP is below threshold, continue to monitor BP closely Repeat BP in 10 minutes If SBP ≥ 160 or DBP ≥ 110, administer labetalol 80 mg IV over 2 minutes; if BP is below threshold, continue to monitor BP closely If SBP ≥ 160 or DBP ≥ 110, administer hydralazine 10 mg IV over 2 minutes; if below threshold, continue to monitor BP closely Repeat BP in 10 minutes and again in 20 minutes If SBP ≥ 160 or DBP ≥ 110 at 20 minutes, obtain emergency consultation from specialist in MFM, internal medicine, anesthesiology, or critical care Give additional antihypertensive medication per specific order as recommended by specialist This algorithm outlines the management of a hypertensive crisis beginning with intravenous labetalol. When severe hypertension is recognized, a responsible provider, such as the patient’s obstetrician or midwife, must be notified. For undelivered patients, fetal surveillance should be initiated if at a viable gestational age. If the patient does not have an IV, one should be started and then 20 mg of labetalol IV should be administered over 2 minutes. During the management of a hypertensive crisis, the BP should be monitored every 10 minutes and if the maternal pulse is < 60 bpm, further doses of IV labetalol should be held. If on repeat assessment, the BP remains in the severe range with a systolic BP of ≥ 160 or a diastolic BP of ≥ 110 and the maternal heart rate is ≥ 60, 40 mg of labetalol should be infused over 2 minutes. If the BP still remains above threshold values after another 10 minutes has passed, 80 mg of labetalol IV over 2 minutes is given. If after the 20 mg, 40 mg, 80 mg, and 80 mg doses of labetalol the systolic BP remains at ≥ 160 or the diastolic BP ≥ 110, then it is time to switch to hydralazine. Hydralazine is given IV at a dose of 10 mg over 2 minutes. If the BP remains above threshold values at 20 minutes after hydralazine administration, then it’s time to call for help. While early consultation is encouraged, if not already done, this is the time to obtain an emergency consultation with a specialist in maternal-fetal medicine, internal medicine, anesthesiology, or critical care for advice. Additional antihypertensive medications should be given as recommended by the specialist until the systolic BP is < 160 and the diastolic BP is < 110. Subsequently, BP should be measured every 10 minutes for the next hour, then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and finally every hour for 4 hours to ensure the BP remains stable and below threshold values. Remember it is important to document one’s management in the medical record including the administration of antihypertensive medications and the patient’s response to treatment. Once BP thresholds are achieved, repeat BP - every 10 minutes for 1 hour - then every 15 minutes for 1 hour - then every 30 minutes for 1 hour - then every hour for 4 hours Institute additional BP monitoring per specific order *Maximum cumulative IV administered doses should not exceed the following: hydralazine 25 mg; labetalol 220 mg in 24 hours. *Hold IV labetalol for maternal pulse under 60

Algorithm: First Line Management with Hydralazine
SBP ≥ 160 or DBP ≥ 110 Notify a provider and institute fetal surveillance if viable Administer hydralazine 5 mg or 10 mg IV over 2 minutes Repeat BP in 10 minutes and again in 20 minutes If SBP ≥ 160 or DBP ≥ 110 at 20 minutes, administer hydralazine 10 mg IV over 2 minutes; if below threshold, continue to monitor BP closely Repeat BP in 10 minutes and again in 20 minutes If SBP ≥160 or DBP ≥ 110 at 20 minutes, administer labetalol 20 mg IV over 2 minutes; if below threshold, continue to monitor BP closely Repeat BP in 10 minutes If SBP ≥ 160 or DBP ≥ 110, administer labetalol 40 mg IV over 2 minutes and obtain emergency consultation from specialist in MFM, internal medicine, anesthesiology, or critical care This algorithm outlines the management of severe hypertension beginning with intravenous hydralazine. Again, when severe hypertension is recognized, a responsible provider must be notified and fetal surveillance started if at a viable gestational age. Hydralazine can be given at a starting dose of 5 or 10 mg IV over 2 minutes. If the BP remains elevated 20 minutes after the initial dose, then a 10 mg dose should be given in a similar fashion, intravenously over a period of 2 minutes. A reminder, BP’s should be measured every 10 minutes during the treatment phase of a hypertensive emergency. If BP’s remains in the severe range with a systolic BP of ≥ 160 or a diastolic BP of ≥ 110 at 20 minutes after the second dose of hydralazine, then it is recommended to switch to labetalol. This is initiated at a starting dose of 20 mg IV over 2 minutes. A 40 mg dose of labetalol is given IV over 2 minutes if the BP still remains above threshold values after 10 minutes. If this second dose of labetalol is needed, an emergency consultation with a specialist in maternal-fetal medicine, internal medicine, anesthesiology, or critical care is recommended if not contacted earlier for advice. Early consultation during the management of a hypertensive crisis is always encouraged. Additional antihypertensive medications should be given as recommended by the specialist until the BP is controlled. Once the systolic and diastolic BP’s are below threshold values, repeat BP assessments as previously outlined should be carried out and a plan for maintenance therapy should be determined. Give additional antihypertensive medication per specific order as recommended by specialist Once BP thresholds are achieved, repeat BP - every 10 minutes for 1 hour - then every 15 minutes for 1 hour - then every 30 minutes for 1 hour - then every hour for 4 hours Institute additional BP monitoring per specific order *Maximum cumulative IV administered doses should not exceed the following: hydralazine 25 mg; labetalol 220 mg in 24 hours.

Agents to Use: No IV Access
If intravenous access is not yet obtained in a pregnant or postpartum woman with severe hypertension, administer: 200 mg of labetalol orally or 10 mg of nifedipine orally (not for sublingual use) Repeat in 30 minutes if systolic blood pressure remains ≥ 160 or diastolic blood pressure ≥ 110 and intravenous access still unavailable On occasion, intravenous access may be difficult and limit the ability to administer firstline antihypertensive medications promptly. In this situation, 200 mg of labetalol or 10 mg of nifedipine can be given orally and repeated in 30 minutes if the systolic BP remains ≥ 160 or the diastolic BP is ≥ 110 and intravenous access is still unavailable. Please note nifedipine is not recommended for sublingual use. In addition, even if the BP responds to oral therapy, every effort should be made to secure IV access during a hypertensive crisis for the administration of magnesium sulfate and additional antihypertensive medications that may be necessary.

Agents to Use: Second Line
If the patient fails to respond to first line agents, recommend emergency consultation with a specialist in one of the following areas for second line management decisions: Maternal Fetal Medicine Internal Medicine Anesthesiology Critical Care There are numerous second line antihypertensive medications that may be used when managing a patient with severe hypertension who fails to adequately respond to labetalol and hydralazine. It is strongly recommended that emergency consultation with a specialist in maternal fetal medicine, internal medicine, anesthesiology, or critical care be done to assist with second line management decisions. Beyond drug selection, these specialists can help with decisions about level and location of subsequent care as well as patient transfer that may be warranted in some cases.

Monitoring: Blood Pressure Management
Maternal Measure blood pressure every 10 minutes during administration of antihypertensive medications Once blood pressure is controlled (<160/110), measure blood pressure: every 10 minutes for 1 hour every 15 minutes for next hour every 30 minutes for next hour every hour for four hours Obtain baseline labs: CBC, platelets, LDH, liver function tests, electrolytes, BUN creatinine, urine protein Fetal Fetal monitoring surveillance as appropriate for gestational age Maternal BP should be measured every 10 minutes during the administration of antihypertensive medications. Once the BP is controlled, indicated by a systolic BP < 160 and a diastolic BP < 110, BP should be measured every 10 minutes for the subsequent hour, every 15 minutes for the next hours, every 30 minutes for the following hour, and then every hour for 4 hours. In addition to beginning magnesium sulfate, baseline labs should be obtained including a CBC with platelets, LDH, liver function tests, electrolytes, BUN and creatinine, and urine protein. Finally, continuous fetal monitoring is recommended when managing a hypertensive crisis, usually beginning at fetal viability at about 24 weeks gestation.

Severe Hypertension in Pregnancy Checklist
Trigger for initiating this checklist is a SBP ≥160 or DBP ≥110 [ ] Initiate magnesium sulfate for seizure prophylaxis (if not already initiated). [ ] Load 4-6 grams of 10% magnesium sulfate in 100 ml solution IV over 20 minutes [ ] Magnesium sulfate on infusion pump [ ] Magnesium sulfate and pump labeled [ ] Magnesium sulfate 10 grams of 50% solution IM (5 grams in each buttock) if no IV access [ ] Magnesium sulfate maintenance 1-2 g/hour continuous infusion Contraindications: pulmonary edema, renal failure, myasthenia gravis Antihypertensive medications Labetalol (20, 40, 80, 80 mg IV* over 2 minutes, escalating doses, repeat every 10 minutes or 200 mg orally if no IV access); avoid in asthma or heart failure, can cause neonatal bradycardia Hydralazine (5-10 mg IV* over 2 minutes, repeat in 20 minutes until target blood pressure is reached) Repeat blood pressure every 10 minutes during administration * Maximum cumulative IV administered doses should not exceed 25 mg hydralazine; 220 mg labetalol in 24 hours. If first line agents are unsuccessful, recommend emergency consultation with a specialist (e.g., MFM, internal medicine, OB anesthesiology, critical care) for second line management decisions Whenever a patient is found to have severe hypertension, defined as a SBP ≥ 160 or DBP ≥ 110 this is an immediate trigger to initiate use of the severe HTN checklist. • First make sure that magnesium sulfate is started for seizure prophylaxis. If magnesium cannot be given, or for recurrent seizures on magnesium, appropriate medications include lorazepam, diazepam, phenytoin or keppra. • Next start the antihypertensive therapy algorithm as previously described. Remember, this starts with labetalol 20 mg and then escalating doses every 10 minutes as needed. Note that the maximum cumulative IV administered doses should not exceed 25 mg hydralazine; 220 mg labetalol in 24 hours. • Either IV labetalol or IV hydralazine can be used initially and if the initial drug regimen first used fails to lower the severe range blood pressure, then the other should be administered as described. • Blood pressure should be checked every 10 minutes. Hydralazine can be used after maximum labetalol dosage has been reached. If these first line agents are unsuccessful, we recommend an emergency consultation with either MFM, internal medicine, OB anesthesia or critical care. • If a patient has severe range pressures and is under 34 weeks, steroids for lung maturity should be given.––Also – remember to re-address venous thromboprophylaxis requirements. • In the postpartum period if blood pressure continues to range 150 systolic or 100 diastolic, antihypertensive therapy should be started. Blood pressures in the 160 systolic or 110 diastolic range should be treated within 1 hour. • Brain imaging should be ordered in those women with an unremitting headache, focal neurologic signs, uncontrolled hypertension, lethargy, confusion, seizure activity or those who are coagulopathic. *This checklist has been made available in poster size and is included in your bundle materials for use on the obstetric unit.

Trigger for initiating this checklist is a SBP ≥160 or DBP ≥110 Anticonvulsant medications (for recurrent seizures or when magnesium is contraindicated): Lorazepam (2-4 mg IV x 1, may repeat x 1 after minutes) Diazepam (5-10 mg IV every 5-10 minutes to maximum dose 30 mg) Phenytoin (15-20 mg/kg IV x 1, may repeat 10 mg/kg IV after 20 minutes if no response); avoid with hypotension, may cause cardiac arrhythmias Keppra (500 mg IV or orally, may repeat in 12 hours); dose adjustment needed if renal impairment Antenatal corticosteroids if < 34 weeks of gestation [ ] Re-address VTE prophylaxis requirement Whenever a patient is found to have severe hypertension, defined as a SBP ≥ 160 or DBP ≥ 110 this is an immediate trigger to initiate use of the severe HTN checklist. • First make sure that magnesium sulfate is started for seizure prophylaxis. If magnesium cannot be given, or for recurrent seizures on magnesium, appropriate medications include lorazepam, diazepam, phenytoin or keppra. • Next start the antihypertensive therapy algorithm as previously described. Remember, this starts with labetalol 20 mg and then escalating doses every 10 minutes as needed. Note that the maximum cumulative IV administered doses should not exceed 25 mg hydralazine; 220 mg labetalol in 24 hours. • Either IV labetalol or IV hydralazine can be used initially and if the initial drug regimen first used fails to lower the severe range blood pressure, then the other should be administered as described. • Blood pressure should be checked every 10 minutes. Hydralazine can be used after maximum labetalol dosage has been reached. If these first line agents are unsuccessful, we recommend an emergency consultation with either MFM, internal medicine, OB anesthesia or critical care. • If a patient has severe range pressures and is under 34 weeks, steroids for lung maturity should be given. ––Also – remember to re-address venous thromboprophylaxis requirements. • In the postpartum period if blood pressure continues to range 150 systolic or 100 diastolic, antihypertensive therapy should be started. Blood pressures in the 160 systolic or 110 diastolic range should be treated within 1 hour. • Brain imaging should be ordered in those women with an unremitting headache, focal neurologic signs, uncontrolled hypertension, lethargy, confusion, seizure activity or those who are coagulopathic. *This checklist has been made available in poster size and is included in your bundle materials for use on the obstetric unit.

Trigger for initiating this checklist is a SBP ≥160 or DBP ≥110 [ ] Plan brain imaging studies if: unremitting headache focal signs and symptoms uncontrolled high blood pressure lethargy confusion seizures abnormal neurologic examination Postpartum: Antihypertensive therapy is suggested for women with persistent postpartum hypertension, SBP of 150 mm Hg or DBP of 100 mm or higher on at least two occasions that are at least 4 hours apart. Persistent SBP of 160 mm Hg or DBP of 110 mm Hg or higher should be treated within 1 hour. Blood pressure monitoring is recommended 72 hours after delivery and/or outpatient surveillance (e.g., visiting nurse evaluation) within 3 days and again 7-10 days after delivery or earlier if persistent symptoms. Whenever a patient is found to have severe hypertension, defined as a SBP ≥ 160 or DBP ≥ 110 this is an immediate trigger to initiate use of the severe HTN checklist. • First make sure that magnesium sulfate is started for seizure prophylaxis. If magnesium cannot be given, or for recurrent seizures on magnesium, appropriate medications include lorazepam, diazepam, phenytoin or keppra. • Next start the antihypertensive therapy algorithm as previously described. Remember, this starts with labetalol 20 mg and then escalating doses every 10 minutes as needed. Note that the maximum cumulative IV administered doses should not exceed 25 mg hydralazine; 220 mg labetalol in 24 hours. • Either IV labetalol or IV hydralazine can be used initially and if the initial drug regimen first used fails to lower the severe range blood pressure, then the other should be administered as described. • Blood pressure should be checked every 10 minutes. Hydralazine can be used after maximum labetalol dosage has been reached. If these first line agents are unsuccessful, we recommend an emergency consultation with either MFM, internal medicine, OB anesthesia or critical care. • If a patient has severe range pressures and is under 34 weeks, steroids for lung maturity should be given. ––Also – remember to re-address venous thromboprophylaxis requirements. • In the postpartum period if blood pressure continues to range 150 systolic or 100 diastolic, antihypertensive therapy should be started. Blood pressures in the 160 systolic or 110 diastolic range should be treated within 1 hour. • Brain imaging should be ordered in those women with an unremitting headache, focal neurologic signs, uncontrolled hypertension, lethargy, confusion, seizure activity or those who are coagulopathic. *This checklist has been made available in poster size and is included in your bundle materials for use on the obstetric unit.

Eclampsia Checklist [ ] Call for assistance (Hospital should identify Rapid Response Team) to location of the event [ ] Check in: OB Attendings/ Fellows/Residents Three RNs Anesthesia Neonatology (if indicated) [ ] Appoint a leader [ ] Appoint a recorder [ ] Appoint a primary RN and secondary personnel [ ] Protect airway [ ] Secure patient in bed, rails up on bed, padding [ ] Lateral decubitus position [ ] Maternal pulse oximetry [ ] IV access/PEC labs [ ] Supplement oxygen (100% non-rebreather) [ ] Bag-mask ventilation on the unit [ ] Suction available [ ] Continuous fetal monitoring (if appropriate) An eclamptic seizure is an immediate trigger to initiate use of the eclampsia checklist. It is the responsibility of the obstetric care team to make certain the components of this checklist are accomplished. Designating a nurse recorder is recommended to help follow the guidance provided within this checklist. First call for assistance, including other OB physicians, 3 nurses, anesthesia and neonatology if appropriate. Assign a primary nurse and secondary personnel. Appoint both a leader and a recorder. Continue to follow the guidance as outlined in the eclampsia checklist. Again, either IV labetalol or IV hydralazine can be used initially and if the initial drug regimen first used fails to lower the severe range blood pressure, then the other should be administered as described. *This checklist has been made available in poster size and is included in your bundle materials for use on the obstetric unit.

Eclampsia Checklist Initial Medications [ ] Load 4-6 grams of 10% magnesium sulfate in 100 ml solution IV over 20 minutes [ ] Magnesium sulfate on infusion pump [ ] Magnesium sulfate and pump labeled [ ] Magnesium sulfate 10 grams of 50% solution IM (5 grams in each buttock) if no IV access [ ] Magnesium sulfate maintenance 1-2 g/hour continuous infusion Contraindications: pulmonary edema, renal failure, myasthenia gravis Anticonvulsant medications (for recurrent seizures or when magnesium sulfate is contraindicated): Lorazepam (2-4 mg IV x 1, may repeat x 1 after minutes) Diazepam (5-10 mg IV every 5-10 minutes to maximum dose 30 mg) Phenytoin (15-20 mg/kg IV x 1, may repeat 10 mg/kg IV after 20 minutes if no response); avoid with hypotension, may cause cardiac arrhythmias Keppra (500 mg IV or orally, may repeat in 12 hours); dose adjustment needed if renal impairment An eclamptic seizure is an immediate trigger to initiate use of the eclampsia checklist. It is the responsibility of the obstetric care team to make certain the components of this checklist are accomplished. Designating a nurse recorder is recommended to help follow the guidance provided within this checklist. First call for assistance, including other OB physicians, 3 nurses, anesthesia and neonatology if appropriate. Assign a primary nurse and secondary personnel. Appoint both a leader and a recorder. Continue to follow the guidance as outlined in the eclampsia checklist. Again, either IV labetalol or IV hydralazine can be used initially and if the initial drug regimen first used fails to lower the severe range blood pressure, then the other should be administered as described. *This checklist has been made available in poster size and is included in your bundle materials for use on the obstetric unit.

Eclampsia Checklist Persistent Seizure [ ] Neuromuscular block and intubate [ ] Obtain radiographic imaging [ ] ICU admission Antihypertensive medications SBP ≥160 or DBP ≥110 Labetalol (20, 40, 80, 80 mg IV* over 2 minutes, escalating doses, repeat every 10 minutes or 200 mg orally if no IV access); avoid in asthma or heart failure, can cause neonatal bradycardia Hydralazine (5-10 mg IV* over 2 minutes, repeat in 20 minutes until target blood pressure is reached) Repeat blood pressure every 10 minutes during administration * Maximum cumulative IV administered doses should not exceed 25 mg hydralazine; 220 mg labetalol in 24 hours. An eclamptic seizure is an immediate trigger to initiate use of the eclampsia checklist. It is the responsibility of the obstetric care team to make certain the components of this checklist are accomplished. Designating a nurse recorder is recommended to help follow the guidance provided within this checklist. First call for assistance, including other OB physicians, 3 nurses, anesthesia and neonatology if appropriate. Assign a primary nurse and secondary personnel. Appoint both a leader and a recorder. Continue to follow the guidance as outlined in the eclampsia checklist. Again, either IV labetalol or IV hydralazine can be used initially and if the initial drug regimen first used fails to lower the severe range blood pressure, then the other should be administered as described. *This checklist has been made available in poster size and is included in your bundle materials for use on the obstetric unit.

Eclampsia Checklist After Seizure [ ] Assess neurologic status every 15 minutes [ ] PEC labs: CBC, Chem 7, LFT, Uric Acid, LDH, T&S, PT/PTT, Fibrinogen, Magnesium [ ] Foley catheter (Hourly I&O. Report output <30 ml/hour) Strict I&O (no less than every 2 hours). Report urine output to the clinician if <30 ml/hr. (Foley catheter should be placed if urine output is borderline or strict I&O cannot be maintained. Urometer should be utilized if the urine output is borderline or <30 ml/hr. Delivery plan Magnesium Toxicity [ ] Stop Magnesium maintenance [ ] Calcium gluconate 1 gram (10 ml of 10% solution) IV over 1-2 minutes [ ] Oral antihypertensive medication postpartum if > 150/100 [ ] Blood pressure monitoring is recommended 72 hours after delivery and/or outpatient surveillance (e.g., visiting nurse evaluation) within 3 days and again 7-10 days after delivery or earlier if persistent symptoms. [ ] Debrief [ ] Document after debrief with the whole team An eclamptic seizure is an immediate trigger to initiate use of the eclampsia checklist. It is the responsibility of the obstetric care team to make certain the components of this checklist are accomplished. Designating a nurse recorder is recommended to help follow the guidance provided within this checklist. First call for assistance, including other OB physicians, 3 nurses, anesthesia and neonatology if appropriate. Assign a primary nurse and secondary personnel. Appoint both a leader and a recorder. Continue to follow the guidance as outlined in the eclampsia checklist. Again, either IV labetalol or IV hydralazine can be used initially and if the initial drug regimen first used fails to lower the severe range blood pressure, then the other should be administered as described. *This checklist has been made available in poster size and is included in your bundle materials for use on the obstetric unit.

Complications & Escalation Process
Maternal (pregnant or postpartum) CNS (seizure, unremitting headache, visual disturbance) Pulmonary edema or cyanosis Epigastric or right upper quadrant pain Impaired liver function Thrombocytopenia Hemolysis Coagulopathy Oliguria* Fetal Abnormal fetal tracing IUGR Certain complications require prompt evaluation and communication with the entire obstetric care team as well as potentially other disciplines, including critical care, anesthesia, neonatology, blood bank, etc. Such complications include, but are not limited to, pulmonary edema, coagulopathy oliguria or abnormal fetal heart rate tracing. • The first line in the escalation process is notifying a nurse or nurse practitioner or PA. If a life-threatening situation is suspected, the OB or MFM should be contacted immediately. • The second line is notifying the OB team, MFM, emergency medicine physician and if indicated, nursing administration, and the blood bank. • The third line is consultation with internal medicine, anesthesia, critical care and neonatology if appropriate. Prompt Evaluation and Communication (if undelivered, plan for delivery) * Oliguria is defined as <30 ml/hr for 2 consecutive hours

Further Evaluation 4 Types of Hypertension Defined
1. Chronic hypertension (of any cause) SBP ≥ 140 or DBP ≥ 90 Prepregnancy or < 20 weeks 2. Gestational hypertension > 20 weeks Absence of proteinuria or systemic signs or symptoms 3. Chronic hypertension with superimposed preeclampsia See Slide.

Further Evaluation 4 Types of Hypertension Defined
4. Preeclampsia-eclampsia SBP ≥ 140 or DBP ≥ 90 Proteinuria with or without signs/symptoms No proteinuria but, with signs, symptoms or lab abnormalities Proteinuria is not required for diagnosis eclampsia seizure in setting of preeclampsia Severe features of preeclampsia SBP ≥ 160 or DBP ≥ 110 on 2 occasions, 4 hours apart Persistent oliguria < 500 ml/24-hour Progressive renal insufficiency Unremitting headache/visual disturbances Pulmonary edema Epigastric/RUQ pain LFTs > 2x normal Platelets < 100K HELLP syndrome (5 grams of proteinuria is no longer a criteria for severe preeclampsia) See Slide.

Monitoring: Change of Status
Once the pregnant patient with severe hypertension is stabilized, consider: Magnesium sulfate for seizure prophylaxis if not already initiated Timing and route for delivery In cases of eclampsia, recommend delivery after stabilization Vaginal delivery is preferred if thought to be attainable in reasonable amount of time in most cases of HELLP syndrome, severe preeclampsia, and chronic hypertension with superimposed preeclampsia If ≥ 34 weeks, deliver Use of antenatal corticosteroids and subsequent pharmacotherapy if preterm (<34 weeks) and expectant management planned Delivery should not be delayed for antenatal steroids in cases complicated by eclampsia, HELLP syndrome, or severe hypertension refractory to treatment, or with maternal symptoms, biochemical/hematological impairment, or fetal compromise Once a patient with severe preeclampsia range blood pressures is stabilized, magnesium sulfate should be given to all pregnant patients > 20 weeks if not already initiated. For those patients with eclampsia, delivery should be undertaken after the patient is stabilized. Vaginal delivery is the preferred mode of delivery if you feel it can be attained in a reasonable amount of time. Of course, if the patient is ≥ 34 weeks, she absolutely should be delivered. If < 34 weeks and expectant management is planned, antenatal corticosteroids should be given. Expectant management (and steroids) should not be undertaken in the case of eclampsia, HELLP syndrome, or severe HTN refractory to treatment, or fetal compromise.

Guidelines for Documentation
On admission, document complete history and complete physical examination including any symptoms associated with preeclampsia Include symptoms of unremitting headaches, visual changes, epigastric pain, fetal activity, vaginal bleeding Baseline BPs over the course of the pregnancy Any medications/drugs taken during the pregnancy (including illicit and OTC) Current vital signs, including oxygen saturation Current and past fetal assessment (including FHR monitoring results, estimated fetal weight, and BPP, as appropriate) Documentation may frequently be looked at as a regulatory requirement and perhaps a bureaucratic necessity. However, it serves two essential roles fundamental to patient safety. First it is a way to enhance effective communication between caregivers. Perhaps even more importantly, the act of writing compels us to organize our thoughts and develop a logical diagnosis. It is important that documentation is ongoing especially as conditions change and remember to describe where the patient is being treated as well as that the provider is at the bedside.

Guidelines for Documentation
In documentation of assessment and plan, include: Whether a diagnosis of preeclampsia has been made and, if not, what steps are being taken to exclude the diagnosis Whether antihypertensive medications are required to control BP and, if so, medication, dose, route, and frequency Current fetal status Whether magnesium sulfate is being initiated for seizure prophylaxis and if so, dosing, route, and duration of therapy Whether delivery is indicated and if so, timing, method, and route. If delivery is not indicated, document under what circumstances it would be indicated Antenatal corticosteroids if < 34 weeks of gestation Ongoing assessment and documentation should be every 30 minutes until the patient is stabilized with blood pressures below the trigger SBP of 160 or DBP of 110 Documentation may frequently be looked at as a regulatory requirement and perhaps a bureaucratic necessity. However, it serves two essential roles fundamental to patient safety. First it is a way to enhance effective communication between caregivers. Perhaps even more importantly, the act of writing compels us to organize our thoughts and develop a logical diagnosis. It is important that documentation is ongoing especially as conditions change and remember to describe where the patient is being treated as well as that the provider is at the bedside.

Postpartum Surveillance: Inpatient
Once a hypertensive emergency is treated and the patient is delivered, additional monitoring, follow-up, and education is necessary to prevent additional morbidity. Preeclampsia and eclampsia can develop postpartum Blood pressure should be measured every 4 hours after delivery until stable. Nonsteroidal anti-inflammatory agents may increase blood pressure in some patients and should not be used in women with elevated blood pressure Patient should not be discharged until blood pressure is well controlled for at least 24 hours Blood pressure peaks 2-6 days after delivery so discharge planning should include repeat blood pressure measurements as outpatient and a review of the signs and symptoms that should prompt the patient to seek medical care Once a hypertensive emergency is treated and the patient is delivered, additional monitoring, follow-up, and education is necessary to prevent additional morbidity. • 75% of deaths from preeclampsia occur after delivery and 41% of deaths from preeclampsia occur more than 2 days after delivery. • Up to 50 % of patients with postpartum preeclampsia did not have preeclampsia before delivery.

Post-Discharge Evaluation: Elevated BP at home, in office, in triage
Postpartum triggers: SBP ≥ 160 or DBP ≥ 110 or SBP ≥ or DBP ≥ with any of the following: unremitting headaches visual disturbances epigastric/RUQ pain Emergency Department treatment (with OB /MICU consultation as needed); antihypertensive therapy is suggested for women with persistent postpartum hypertension, SBP > 150 or DBP > 100 on at least two occasions that are at least 4 hours apart. Persistent SBP > 160 or DBP > 110 should be treated within 1 hour. Hypertension ≥ 140 SBP or ≥ 90 DBP requires admission for management even if there is good response to initial treatment. Good response to antihypertensive treatment and asymptomatic Signs and symptoms of eclampsia, abnormal neurological evaluation, congestive heart failure, renal failure, coagulopathy, poor response to antihypertensive treatment Admit for further observation and management (e.g., L&D, ICU, unit with telemetry) Recommend emergency consultation for further evaluation with a specialist (e.g., MFM, internal medicine, OB anesthesiology, critical care)

Discharge Information & Planning: Postpartum Patients without Preeclampsia
All patients get a patient information sheet describing in lay terms the signs and symptoms of preeclampsia All new nursing and physician staff receive an information sheet regarding hypertension in pregnancy and post partum Some patients will not follow-up as directed. At times this is due to lack of insurance coverage for follow-up visits or home nursing care. Sometimes it is because they do not understand the potential serious nature of postpartum preeclampsia. That is why patient and staff education is so important. It is strongly recommended that high risk patients (those with chronic hypertension, diagnosed eclampsia/preeclampsia, gestational hypertension, or significant labile blood pressures) have a home or ambulatory visit arranged 2-3 days after discharge. Home blood pressure monitoring may be better than doing nothing at all, but it is not as good as seeing a provider. For the majority of patients with postpartum preeclampsia, 87 % have headache as the presenting complaint. It may be hard in the postpartum period to evaluate symptoms, both for the patient and the caregiver. This is especially true as up to 40% of new mothers report headaches in the first month after delivery. *Model patient discharge instructions are provided within your bundle materials as well as a signs and symptoms patient information sheet from the Preeclampsia Foundation. These instructions can be provided for both patients with hypertensive issues identified during pregnancy and low risk patients. These instructions can be enhanced with hospital specific detail such as appropriate contact numbers.

Discharge Information & Planning: Postpartum Patients with a Diagnosis of Preeclampsia
Patients get a patient information sheet describing in lay terms the signs and symptoms of preeclampsia as well as the importance of prompt reporting of this information to their health care provider Blood pressure monitoring is recommended 72 hours after delivery and/or outpatient surveillance (e.g., visiting nurse evaluation) within 3 days and again days after delivery or earlier if persistent symptoms. Some patients will not follow-up as directed. At times this is due to lack of insurance coverage for follow-up visits or home nursing care. Sometimes it is because they do not understand the potential serious nature of postpartum preeclampsia. That is why patient and staff education is so important. It is strongly recommended that high risk patients (those with chronic hypertension, diagnosed eclampsia/preeclampsia, gestational hypertension, or significant labile blood pressures) have a home or ambulatory visit arranged 2-3 days after discharge. Home blood pressure monitoring may be better than doing nothing at all, but it is not as good as seeing a provider. For the majority of patients with postpartum preeclampsia, 87 % have headache as the presenting complaint. It may be hard in the postpartum period to evaluate symptoms, both for the patient and the caregiver. This is especially true as up to 40% of new mothers report headaches in the first month after delivery. *Model patient discharge instructions are provided within your bundle materials as well as a signs and symptoms patient information sheet from the Preeclampsia Foundation. These instructions can be provided for both patients with hypertensive issues identified during pregnancy and low risk patients. These instructions can be enhanced with hospital specific detail such as appropriate contact numbers.

Emergency Department: Postpartum Preeclampsia Checklist
Triage patients less than 6 weeks postpartum as follows: [ ] Core evaluation and assessment [ ] If BP > 160/110 or 140/90 with: Unremitting headaches Visual disturbance Epigastric pain [ ] Begin stabilization [ ] Call for Obstetric consult immediately [ ] OBS contact documented [ ] Call MFM/MICU consult immediately for refractory blood pressure [ ] Labs should include: CBC PT PTT Fibrinogen CMP Uric Acid Hepatic function panel Type and Screen [ ] Initiate Intravenous Access Many postpartum women will present with symptoms to the Emergency Department or to their family practitioner or internist. None of these care providers is likely to have, or be familiar with the use of magnesium sulfate for preeclampsia. *This checklist has been made available in poster size and is included in your bundle materials for use in your hospital where appropriate.

[ ] Assess neurologic status LOC/arousal/orientation/behavior Deep tendon reflexes Speech [ ] Assess vital signs including oxygen saturation [ ] Assess complaints and report; unremitting headaches, epigastric pain, visual disturbances, speech difficulties, lateralizing neuro signs [ ] Place Foley catheter [ ] Strict I&O report output less than 30 ml/hr for 2 hours [ ] Plan brain imaging studies if: Unremitting headache Focal signs and symptoms Uncontrolled high blood pressure Lethargy Confusion Seizures Abnormal neurologic examination Many postpartum women will present with symptoms to the Emergency Department or to their family practitioner or internist. None of these care providers is likely to have, or be familiar with the use of magnesium sulfate for preeclampsia. *This checklist has been made available in poster size and is included in your bundle materials for use in your hospital where appropriate.

Initial medications [ ] Load 4-6 grams of 10% magnesium sulfate in 100 ml solution IV over 20 minutes [ ] Magnesium sulfate on infusion pump [ ] Magnesium sulfate and pump labeled [ ] Magnesium sulfate 10 grams of 50% solution IM (5 grams in each buttock) if no IV access [ ] Magnesium sulfate maintenance 1-2 g/hour continuous infusion Contraindications: pulmonary edema, renal failure, myasthenia gravis Antihypertensive medications (see relevant algorithm in intrapartum section) Labetalol (20, 40, 80, 80 mg IV* over 2 minutes, escalating doses, repeat every 10 minutes or 200 mg orally if no IV access); avoid in asthma or heart failure, can cause neonatal bradycardia Hydralazine (5-10 mg IV* over 2 minutes, repeat in 20 minutes until target blood pressure is reached) Repeat blood pressure every 10 minutes during administration * Maximum cumulative IV administered doses should not exceed 25 mg hydralazine; 220 mg labetalol in 24 hours. If magnesium sulfate is contraindicated: Keppra 500 mg PO or IV every 12 hours Many postpartum women will present with symptoms to the Emergency Department or to their family practitioner or internist. None of these care providers is likely to have, or be familiar with the use of magnesium sulfate for preeclampsia. *This checklist has been made available in poster size and is included in your bundle materials for use in your hospital where appropriate.

Conclusion Risk reduction and successful, safe clinical outcomes for women with preeclampsia, eclampsia, or chronic hypertension with superimposed preeclampsia require avoidance and management of severe systolic and severe diastolic hypertension Increasing evidence indicates that standardization of care improves patient outcomes Systolic BP ≥ 160 mm Hg or diastolic BP ≥ 110 mm Hg warrant prompt evaluation at the bedside and treatment to decrease maternal morbidity and mortality See Slide Content.

Maternal Safety Bundle for Severe Hypertension in Pregnancy

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Maternal Safety Bundle for Severe Hypertension in Pregnancy

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Presentation on theme: "Maternal Safety Bundle for Severe Hypertension in Pregnancy"— Presentation transcript:

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