Conservative Management of

Preeclampsia (CMOP) at East

Carolina University and Vidant
Medical Center
The Balancing Act
James E. deVente, MD/PhD
Associate Professor
Medical Director of Labor and Delivery
Department of Obstetrics and Gynecology
Brody School of Medicine

CMOP

Outline

The Balancing Act

Brief History of the Conservative Management of Preeclampsia at

our institution (Data)

The Preeclamptic Balancing Act

Proper Diagnosis
Education for MD and RN (Examples)
CMOP protocol
Prevalence of Pre-eclampsia at Vidant Medical Center (Data)

Proper Management
Severe BP treatment < 1hr Data (Data)
Steroids < 34 weeks (Data)

Proper Discharge
Patient Education and Follow-up (example)

Lesson Learned / Opportunities Identified

Balancing Act
Brief History of the Conservative Management of Preeclampsia at our
institution
Expectant
management
should be
considered for
women remote
from term who
have mild
preeclampsia

2001
2009

S c h i ff E , Fr i d e m a n S A , S i b a i B .
Conse rva tive ma nag emen t o f severe
p reecl ampsia remote from term. Am J
Obstet Gynecol 1994;84: 626-630.

Sibai B. Diagnosis and Management of

gestational hypertension and
preeclampsia. Am J Obstet Gynecol
2003; 102: 181-192.

S i b ai B, Bar to n JR. Exp ectan t

man ag eme nt of severe p re ecla mp sia
remote from term: patient selection,
treatment, and delivery indications. Am
J Obstet Gynecol 2007; 514: 1-9.

2008 ACOG Compendium

Practice Bulletin number 33

PRETERM DELIVERY RATE/ VIDANT MEDICAL CENTER 2009 - 2013

120

100

BIRTHS PER MONTH

80

60

40

20

22.5% decrease in infants

delivered less than 37 weeks
29.2% decrease in infants
delivered less than 32 weeks

3. Live Births < 37

wks
Linear (3. Live
Births < 37 wks)
4. Live Births < 32
wks
Linear (4. Live
Births < 32 wks)

INFANTS REQURING NICU/ VIDANT MEDICAL CENTER 2009 - 2013

60

50

40
INFANTS PER MONTH
30

20

10

29.3% decrease in infants >33

weeks & transferred to NICU
31.3% decrease in total infants
requiring

15. Birth > 33 wks & Transfer

to NICU
Linear (15. Birth > 33 wks &
Transfer to NICU)
NICU Baby
Linear (NICU Baby)

INFANTS WITH APGARS < 6 at FIVE MINUTES 2009 - 2013

40
12. APGARS <6 at 5 Minutes

35

Linear (12. APGARS <6 at 5

Minutes)

30
INFANTS
PER MONTH
25
20
15
10
5
0

This represents a 43.0%

decrease in infants with
APGARs <6 at five minutes

Immediate Protocol Vs. Expectant

Protocol

Maternal/Fetal
Assessment

Maternal/Fetal
Assessment

Mag sulfate for

seizure
prophylaxis

GA <34 wks w/o

BMZ

BMZ x2 doses
for FLM
IV mag sulfate
Steroids FLM
Continuous EFM

GA>34 wks
GA>32 wks with
steroids
GA<23 wks
*Any CI to
expectant mgmt

12 urine TP
Lab evaluation
Serial exams
DELIVERY

DELIVERY

N= 124 patients < 34 week

N= 112 patients < 34 week

Immediate Protocol Vs. Expectant

Protocol
Study

Gest.
Age
Gained
(d)

Abrupti
on

Birth wt
(g)

Fetal
deat
h

Apgar
1 min

Apgar
5 min

Mat
Death

ECU

6.69 +/8.36

n=3

1399.6
+/- 517

n=1

5.28 +/2.54

7.11
+/- 2.0

n=1

Sibai
et al

15.4 +/6.6

n=2

1622 +/360

n=0

5.5

n=0

Odendaa
let al

7.1

n=4

1420 +/350

n=1

-------

We were gaining an
average of a week to
our pre-eclamptics
<34 weeks

---------

n=0

So why do we care about 7 days?

IVH

SEP

$$

RDS

SIS

NEC

CP

P
O
R

you increase gestational age you decrease the complication of prematurity

Preeclamptic Balancing Act

Stroke
Hemorrhage
Renal Failure
Hepatic Failure
Pulmonary Edema
Retinal detachment
Etc

Prematurity
ROP
Sepsis
NEC
IVH
CP
RDS
Etc

CMOP

Culture
Building

Proper Diagnosis

Physician Education

Hospital Administrator engagement

Nurse Education

Patient Engagement

Proper Diagnosis
All HTN Dz and Sever Preeclampsia
25%
All HTN Dz

21%

20%

18%

15%14%
11%

12%

12%

13%

14%

6%

5%

0%

14%

10%

Percent
10%9% of total9%deliveries
9%
8%

17%

8%
7%

8%
6%

Total deliveries:
2931
All HTN Dz: 428
(15%)
Sev. Preecl: 199
(7%)

Proper Diagnosis
Delivery Indication
Severe Preecl
Gest. HTN

Super Imposed Preecl

All Other
28%

15%
18%

39%

Proper Management
Severe Hypertension treated within 1 Hour
100%
90%
80%
67%

70%

61%

60%

52%

10%
0%

64%

43%

40%
20%

75%

52%

50%
30%

78%

73%

28%

Getting
Better!

Proper Management
Sev. Preecl Delivered less than 32 and 34 week
60%
50%
40%

< 34 week
Deliveries
44%
38%

41%
36%

30%

26%

Percent of Total Sev. Preecl.

20%17%
10%
0%
-10%

9%

17% of Sev.
Preecl
are
43%
delivered
<32 wks
24 % are
delived
<
12%
12%
34 wks

Proper Management
Full Course of Steroids given prior to delivery
120%
100%

100%
86%

80%

70%

67%

60%

50%

Percent of Total Sev. Preecl.

40%
20%
0%

Full Course of
Steroids

17% of Sev.
Preecl are
delivered
<32 wks
67%
24 50%
% are
50%
delivered <
34 wks

Proper Discharge
All patients with GHTN/Preeeclampsia are given a 1
week post-partum BP check appt.
All patients are given verbal education on
Hypertension in pregnancy (and this is documented
in the RN Notes)

Lessons and Opportunities

1. Taking an accurate BP can be extremely difficult in some patients
2. Antihypertensive drugs need to be readily available
3. Making a Diagnosis of Super imposed Preeclampsia can
sometimes be quite challenging be patient with your patient and
your self
4. Patient Education has been very challenging to execute in a
reliable fashion
5. Preeclamptic patients represent a significant portion of Obstetrical <
30 day Readmissions thus, underscoring the importance of early
follow-up and effective patient education
6. A dedicated, educated and passionate Antepartum Unit
Team is Foundational to safely expectantly manage Severe
Preeclamptics
7. The extra time, effort, and aggravation to both the patient and
the clinical team is SO WORTH IT! the fetal dividends are huge

Referrences
Evaluation and management of severe preeclampsia before 34 weeks gestation.
SMFM Clinical Opinion. Am J Obstet Gynecol 2007; 191-197.
Haddad B and Sibai BM. Expectant Management in Pregnancies with Severe preeclampsia. Semin Perinatol 2009; 33: 143-151.
Haddad B, Deis S, Goffinet F, Paniel BJ, et. Al. Maternal and perinatal outcomes
during expectant management of 239 severe preeclamptic women between 24 and
33 weeks gestation. Am J Obstet Gynecol 2004; 190: 1590-1597.
Hall DR, Odendall HJ, Steyn DW. Expectant management of severe pre-eclampsia in
the mid-trimester. Eur J Obstet Gynecol Reprod Biol 2001;96: 168-172.
Schiff E, Frideman SA, Sibai B. Conservative management of severe preeclampsia
remote from term. Am J Obstet Gynecol 1994;84: 626-630.
Sibai B. Diagnosis and Management of gestational hypertension and preeclampsia.
Am J Obstet Gynecol 2003; 102: 181-192.
Sibai B, Barton JR. Expectant management of severe preeclampsia remote from
term: patient selection, treatment, and delivery indications. Am J Obstet Gynecol
2007; 514: 1-9.
Steegers EA, Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet 2010;
376: 631-644.