1. Preeclampsia Maternal Affinity Group October 23, 2013

2. Objectives Risks factors of Preeclampsia Name 5 symptoms of Preeclampsia Understand PERT (Preeclampsia Early Recognition Tool) Identify contents of Preeclampsia toolkit

3. It’s just high blood pressure! One of the biggest risks for maternal mortality If undetected, preeclampsia can lead to eclampsia which is one of the top 5 causes of maternal and fetal death in the world. ▫13% of all maternal deaths In US, accounts for 18% of all maternal deaths Causes 15% of premature deaths in industrialized countries AND….

4. It’s just high blood pressure! Most can be prevented with early detection of risks and symptoms!!

5. Risk Factors Multiple pregnancies Obesity and primigravida Medical History of chronic high blood pressure, renal disease, or diabetes Pregnancy in early teens or past 40 Preexisting: ▫Hypertension ▫Diabetes ▫Rheumatoid Arthritis or Lupus ▫Kidney Disease

7. Symptoms Headache Blurred Vision Upper abdominal pain Unexplained anxiety Seizures Increased weight gain Decreased urine output

8. Diagnosis Blood pressure of 140 mmHg systolic or higher or 90 mmHg diastolic or higher that occurs after 20 weeks gestation in a women with previously normal blood pressure. Proteinuria, defined as urinary excretion of 0.3 grams protein or higher in a 24 - hour urine specimen. New onset hypertension without proteinuria but with signs and symptoms of major end organ involvement such as headache, upper abdominal pain, hepatic dysfunction, pulmonary edema, or severe renal dysfunction, would potentially be indicative of “atypical” preeclampsia.

9. Blood Pressure Readings Competency with accurately recording blood pressures Do not have patient lay on left side just to get a better reading

10. Acute Treatment Antihypertensive medications administered within 1 hour and ideally within 30 minutes of arrival at a healthcare facility for blood pressures of 160 systolic, and/or 105 -110 diastolic or greater is a critical initial step in decreasing morbidity and mortality. Magnesium sulfate therapy for seizure prophylaxis should be administered to any patients with: ▫Severe preeclampsia, ▫Preeclampsia with severe features, also known as atypical (subjective neurological symptoms such as headache or blurry vision or right upper quadrant or epigastric abdominal pain) AND ▫Should be considered in patients with mild preeclampsia (preeclampsia without severe features). Magnesium sulfate is the approved initial therapy for an eclamptic seizure.

11. Adapted from the Modified Obstetric Early Warning System (MEOWS) 2003-05

12. PERT Yellow = Worrisome Increase assessment frequency # of Triggers:To Do: 1Notify Provider >/= 2Notify Charge RN In-person Evaluation Order labs/tests Anesthesia Consult Consider Mag Sulfate Supplemental O2 Green = Normal Proceed with Protocol

13. PERT RED=SEVERE Trigger: 1 of any type listed below 1 of any type Awareness Headache Visual BP Respiration, SOB, O2 Sat Chest Pain Immediate Evaluation Transfer to higher acuity level 1:1 Staff Ratio Consider Neurology consult CT Scan R/O SAH/Intracranial Hemorrhage Labetalol/Hydralazine in 30 min In-person evaluation Magnesium Sulfate loading or maintenance infusion Consider CT Angiogram O2 at 10/L R/O pulmonary edema CXR

14. KEY LEARNING POINTS 1. Assess for signs and symptoms of worsening or severe preeclampsia and notify provider if any of these are present: ▫Increasing blood pressure ▫Headache ▫Altered level of consciousness –agitation, restless, lethargy, hallucinations, confusion ▫Visual disturbances –blurred vision, floaters, spots, blind spot ▫Upper abdominal pain ▫Urine output <30 ml/hr ▫Shortness of breath

15. KEY LEARNING POINTS 1. Assess for signs and symptoms of worsening or severe preeclampsia and notify provider if any of these are present: ▫Complaints of chest pain ▫SaO2 < 95% ▫Cough ▫Tachypnea > 26 breaths per minute ▫Tachycardia > 100 bpm ▫Adventitious breath sounds ▫Eclamptic seizure ▫Magnesium toxicity

16. KEY LEARNING POINTS 2. Patient care assignments should take into account the level and expertise of the clinician or nurse assigned to care. ▫Patients diagnosed with severe preeclampsia should be staffed with a 1:1 nurse to patient ratio, with the most experienced nurse available. 3. Women with severe preeclampsia should receive care by a multi-disciplinary team. ▫The team should consist of an obstetric provider credentialed to perform cesarean sections, nursing, anesthesia, NICU, laboratory, blood bank, social work, and other sub-specialties as needed.

18. References http://www.pqcnc.org/documents/cmop/Preecl ampsiaToolkitSubmissionDraft20130805.pdfhttp://www.pqcnc.org/documents/cmop/Preecl ampsiaToolkitSubmissionDraft20130805.pdf http://www.preeclampsia.org/pdf/Preeclampsia %20Fact%20sheet%20v2.pdfhttp://www.preeclampsia.org/pdf/Preeclampsia %20Fact%20sheet%20v2.pdf http://www.rightdiagnosis.com/p/preeclampsia /stats.htmhttp://www.rightdiagnosis.com/p/preeclampsia /stats.htm

19. Questions?? Lynne Hall 770-249-4525 lhall@gha.org