Managing Preeclampsia throughClinical and Non-ClinicalInterventions

Janice Hackney, RN, BSN, LCCE

Ekua Ansah-Samuels MPH, CLC, Doula

NYSPA Conference June 8, 2017

Workshop Outline

• The Worsening Situation: Maternal Mortality (Pregnancy-related)and Severe Maternal Morbidity in the US

• The Role of Hypertensive Disorders in Pregnancy in MaternalMorality & Severe Maternal Morbidity

• Risk Factors, Symptoms, & Treatments

• Clinical Interventions

• Non-clinical Interventions

• Addressing Barriers in Care & Management

• Raising Awareness, Educating Families & Advocacy

The Worsening Situation: Alarming US Reality

There are 4 categories of HypertensiveDisorders in Pregnancy

1. Chronic Hypertension• SBP ≥ 140 or DBP ≥ 90 • Pre-pregnancy or <20 weeks gestation

2. Gestational Hypertension• SBP ≥ 140 or DBP ≥ 90; • > 20 weeks• Absence of proteinuria or systemic signs/symptoms

3. Pre–Eclampsia – Eclampsia• SBP ≥ 140 or DBP ≥ 90• Proteinuria with or without signs/symptoms• Presentation of signs/symptoms/lab abnormalities but no proteinuria

*Proteinuria is not required for diagnosis eclampsia seizure in setting of pre-eclampsia

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There are 4 categories of HypertensiveDisorders in Pregnancy

4. Chronic Hypertension + Superimposed Pre-eclampsia• Pre-eclampsia with severe features

-2 severe BP values (SBP>160 or DBP>110) obtained 15-60 minutes apart-Persistent oliguria<500ml/24hrs.–Progressive renal insufficiency

-Unremitting headache/visual disturbances–pulmonary edema-Epigastric/RUQ pain

-LFTs>2x normal–platelets<100k

–HELLP syndrome*5 gr of proteinuria no longer criteria for severe preeclampsia

Pre-Eclampsia can cause

• Poor blood flow to the placenta resulting in:• Inter Uterine Growth Restriction• Breathing Difficulties• Premature Birth

• Placental abruption:• The placenta separates from the inner wall of the uterus.• In severe cases, there may be heavy bleeding, which can damage the placenta.

• Eclampsia:• Basically a combination of preeclampsia and seizures.• Permanent brain damage• Death for mom and baby

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Pre-Eclampsia may also cause the following

• HELLP syndrome: Hemolysis, Elevated Liver Enzymes, and LowPlatelet count; Can be life-threatening very quickly, for both themother and the baby. Most commonly occurs right after giving birth, butcan appear at any time of pregnancy.

• Preeclampsia can have some long-term consequences for the developingbaby. High blood pressure in pregnant women may affect the baby'scognitive skills, which can carry through into later life.

• Pre Eclampsia is also associated w/ significant increased risk of CVD• Of those who have pre-eclampsia, 2/3 will die from heart disease

Rick Factors

• African American Women

• 1st – time pregnancies

• Chronic Hypertension

• Diabetes

• Previous history of pre-eclampsia

• Family history of pre-eclampsia

• Advanced Maternal Age (40+)or <18 yo

• Obesity

• Pregnant with Multiples

• IVF

• Anemia Disorders

• Sickle Cell Disease

0%

10%

20%

30%

40%

50%

60%

70%

Florida California

Personal Decisions(delay in seeking care)

Lack of Knowledge(regarding theseverity of asymptom)

FL-PAMR 2009-2013 CA-PAMR 2002-2004

Where are the gaps in care?Community factors in MM from HDP

PAMR Report 1999-2012 Florida Pregnancy-Associated Mortality Review

Symptoms

• Swelling (edema)

• Headaches (Unrelieved byacetaminophen)

• Nausea

• Neck Pain

• Blurred Vision

• Dizziness/Confusion

• Decreased Urine output

• Sudden weight gain

• Difficulty Breathing

• Unexplained anxiety

• Just not feeling right

5 Steps of Management

1. Recognize Symptoms

2. Blood Pressure Control

3. Seizure prevention

4. Delivery

5. Post partum surveillance

Maternal Recognition Improves Outcomes

“The best way to diagnose preeclampsia is to listen to your patients.”~ Dr. Baha Sibai

© 2017 Preeclampsia Foundation

Clinical Interventions

• Medication• Magnesium Sulfate

• Anti Hypertensive Medications (if needed)

• Anticonvulsant medications (if a seizure occurs)

• Hospitalization - In the hospital doctors monitor both mom andbaby's well-being

• Delivery - doctors may recommend inducing labor right away orscheduling a C-section

ACOG District II Safe Motherhood Initiative

• Severe Hypertensive Bundle is 1 of 3 that have been developed toaddress the 3 leading causes of maternal mortality

• The others are for Hemorrhage and Venous Thromboembolism

• Provides standardized protocol for handling the condition

• Focus on 4Rs - Readiness – Recognition – Response – Reporting

• Key Elements include:• RISK ASSESSMENT & PREVENTION

• • Diagnostic Criteria • When to Treat • Agents to Use • Monitoring

• READINESS & RESPONSE• Complications & Escalation Process • Further Evaluation • Change of Status• Postpartum Surveillance

Janice’s Story

• Photo Here

• Use non-medical plain language• Organize information into 2 or 3 components (“chunk &

check”)• Use “teach back” to confirm understanding with open-

ended Q’s• Do not assume patients’ literacy levels or understanding

by appearance• Stop, look and listen!• Use proven tools that support consistent message• Messages must be repeated to be remembered• Use multiple teaching strategies to accommodate

learning styles

Key Strategies for EffectivePatient Communication

ACOG Hypertension in Pregnancy guidelines (2013)

Barriers

• Denial – Expectant Mom don’t want to be negative

• Education = Scary

• All health care providers are not always on the same page

• EMR and laptops at visits = no face to face

• 2nd time moms know everything

• Moms do not practice self-care

• Information overload

• Lack of confidence in Hospitals and Doctors

• Hospitals and Doctors can be intimidating

Addressing Barriers

• Provide information from a general standpoint• Stick to what, why, severity

• Validate what moms already know and THEN give more info.

• Affirm self-care is not selfish

• Expand education to family members and partners

• Know the culture you are working with

• Passports

• Community Health Workers & Doulas

Addressing Barriers cont.

• Remembering that delivery isn’t always the cure• Late post partum eclampsia is an example

• Timing is key

• Hospital discharge papers for ALL moms need to includeinstructions on symptoms of Eclampsia

• Currently, anyone who has an episode gets instructions and homecarenursing services upon discharge

• Pre-Eclampsia episode can happen up to 60 days postpartum

• Mom is the 1st responder

Non-Clinical Interventions that Work

• Consistent messaging around Self Care being a Major Priority for women

• Clinical Care Coordination – assist women in taking steps towards clinical care

• Escorts – address quality of care issues

• Diverse efforts to secure stable housing – based on each individual woman’sneeds and circumstances

• Education for staff on identifying and supporting women experiencing IntimatePartner Violence – Provider skills helps women feel safe and keeps themengaged.

• Doula Care – Tactical and practical support

• Mental Health Counseling and referrals

• Fun activities for mom and babies that promote wellness and encouragecommunity

• Continuous Health Education

Pathways of Non-Clinical Interventions

• Unstable Housing, Domestic Violence, Work FamilyConflict Insufficient Earning Poor Quality of Care

• Stress, Depression, Anxiety, Lack of support

• Poor Self Care, Chronic Illness, Distrust in the Healthcare

System, Poor Management of Chronic Diseases

Tactical SupportCase ManagementStakeholder &Provider EngagementResourcesAdvocacy

Practical Physical &Emotional SupportDoula CareFun activities

Consistent messagingModeling of self careAssistance withacquiring clinical carethat meets needsCare coordination

Improved Physical

and Mental Health,

Safer Births

Your Patient Education Toolkit

Video available in English and Spanish onYouTube™or for adding to your websiteEnglish views: 100,000Spanish views: 210,000

These and other patienteducation materials areavailable in multiplelanguages and can beordered fromwww.preeclampsia.org/store

© 2017 Preeclampsia Foundation

June 17 – Long Island, NY

June 24 – New York City, NY

Register or Donate Online at www.promisewalk.org

Walk * Give * Tell your patients

Come walk with us!

References

• ACOG. (2015, November ). Maternal Safety Bundle for Severe Hypertension in Pregnancy. Retrieved from ACOG District II -Safe Motherhood Initiative: https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/HTNSlideSetNov2015Updated.pdf?dmc=1&ts=20170526T1555427558

• American Heart Association. (2014, February). Preeclampsia doubles women’s stroke risk, quadruples later high bloodpressure risk. Retrieved from American Heart Association News: http://news.heart.org/preeclampsia-doubles-womens-stroke-risk-quadruples-later-high-blood-pressure-risk/

• Columbia University Mailman School of Public Health. (2013, November ). Maternal and Reproductive Health: Pre-eclampsia Rates on the Rise in the U.S. Retrieved from Columbia University Mailman School of Public Health .

• Nina Martin, R. M. (2017, May 12). NPR NEWS INVESTIGATIONS. Retrieved from Focus On Infants During Childbirth LeavesU.S. Moms In Danger: http://www.npr.org/2017/05/12/527806002/focus-on-infants-during-childbirth-leaves-u-s-moms-in-danger

• Preeclampsia Foundation. (2010). About Preeclampsia. Retrieved from Preeclampsia Foundation:https://www.preeclampsia.org/health-information

• Soile Tuovinen, M. K.-K. (2012, October). Hypertensive disorders in pregnancy and cognitive decline in the offspring up toold age. Neurology, 79(15), 1578-1582.

• You WB, W. M. (2012, May). Improving patient understanding of preeclampsia: a randomized controlled trial. AmericanJournal of Obstetrics and Gynecology, 206(5), 431.e1–431.e5.

Acknowledgements

• NYSPA Conference Planning Committee

• The Pre-Eclampsia Foundation

• NMPP’s Maternal Intentions staff and consortium members

• Merck for Mothers

• ACOG

• Community Based Organizations serving pregnant women

• Community Health Workers, Case Managers, & Doulas

• MCH Clinicians

Questions?