Conservative Management of Preeclampsia (C-MOP)

PQCNC Annual Meeting

January 7, 2014

Arthur Ollendorff, MD
MAHEC OB/GYN Specialists Asheville, NC
Clinical Professor of OB/GYN University of North Carolina SOM Arthur.Ollendorff@mahec.net

Outline for Afternoon

2:00-2:45 Elliott Mane
Quality Improvement in Preeclampsia

2:50-3:10 Kathy & Clark Ellis

The Familys Perspective

3:10-3:35 Arthur Ollendorff

Classification of Hypertension in Pregnancy

3:45-3:55 Break 3:55-4:40 Arthur Ollendorff

CMOP Action Plan Review

ACOG Publication-October 2013

From the ACOG document

The information in Hypertension in Pregnancy should not be viewed as a body of rigid rules. The guidelines are general and intended to be adapted to many different situations, taking into account the needs and resources particular to the locality, the institution, or the type of practice. Variations and innovations that improve the quality of patient care are to be encouraged rather than restricted. The purpose of these guidelines will be well served if they provide a firm basis on which local norms may be built.
Hypertension In Pregnancy (2013). ACOG Hypertension In Pregnancy Taskforce.

My Favorite Definition of EBM

Evidence-Based Medicine is critical appraisal of the literature applied through the clinicians experience and judgment

The Modified Evidence Pyramid

Quality of Evidence
High

Applicability
Large Populations

Low

Individual Patient

Old CCNC Pathway Classification of Hypertensive Disorders of Pregnancy

Gestational Hypertension Mild Preeclampsia Severe Gestational Hypertension Severe Preeclampsia Chronic Hypertension with Superimposed Preeclampsia

CCNC Pregnancy Medical Home Program Care Pathway: Management of women with hypertensive disorders of pregnancy. August 2012.

ACOG Classification Hypertensive In Pregnancy

Chronic hypertension Gestational hypertension Preeclampsia/Eclampsia

without severe features with severe features

Chronic hypertension with superimposed preeclampsia

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

What Has Changed

Terminology

Preeclampsia without severe features

Formerly called mild preeclampsia

Preeclampsia with severe features

Formerly called severe preeclampsia

Blood pressure criteria are 4 hours apart rather than 6 hours apart

Severe Features of Preeclampsia

Systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher on two occasions at least 4 hours apart while the patient is on bed rest Thrombocytopenia (platelet count less than 100,000/microliter) Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice normal concentration), severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, or both

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

Severe Features of Preeclampsia

Progressive renal insufficiency (serum creatinine concentration greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease) Pulmonary edema New-onset cerebral or visual disturbances

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

What Else Has Changed

Preeclampsia can exist without proteinuria

Preeclampsia with severe features can be diagnosed with any severe feature
Severe Gestational Hypertension no longer exists

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

Changing Providers Behavior Is Like

A Stepwise Approach
1.

Was elevated blood pressure present before 20 weeks gestational age?

Yes Classification can only be

Chronic hypertension Chronic hypertension with superimposed preeclampsia

No Classification can be
Preeclampsia Gestational hypertension

A Stepwise Approach
2.

Patient with new blood pressure elevation after 20 weeks gestational age. Are there severe features present

Yes Classify as Preeclampsia with severe features No Evaluate for proteinuria

Severe Features of Preeclampsia

Blood Pressure > 160/110 Platelets < 100,000 Impaired liver function based on LFT or symptoms Renal insufficiency Pulmonary edema Cerebral or visual disturbances

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

A Stepwise Approach
3.

Patient with new onset elevated blood pressure and no severe features. Perform 24 hour urine for protein.

< 300 mg - classify as gestational hypertension 300 mg - classify as preeclampsia without severe features

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

ACOGs Guidance on Clinical Conundrums

Subjective symptoms that define severe features Diagnosing chronic hypertension with superimposed preeclampsia

Subjective Symptoms

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 Pregnancy Taskforce.

Chronic hypertension with superimposed preeclampsia

Superimposed preeclampsia should be considered when there is

a sudden increase in BP that was previously well controlled sudden, substantial and sustained increase in proteinuria development of severe features

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

Superimposed Preeclampsia
Clinicians should recognize that there is often ambiguity in the diagnosis of superimposed preeclampsia and that the clinical spectrum of disease is broad Increased surveillance but not intervention (e.g. delivery) is warranted even if the diagnosis is suspected and not definitive

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

When In Doubt Use This Resource

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

C-MOP Participating Sites

Caromont Cleveland Regional CMC-Main CMC-Northeast Columbus Duke Forsyth Granville McDowell

Mission New Hanover Novant-Huntersville Rex Transylvania UNC Vidant Womack

January 2, 2014

C-MOP Action Plan

C-MOP Action Plan

C-MOP Action Plan

C-MOP Action Plan