treating maternal hypertension hp2020 objective use the same codes. u.s. maternal mortality data is...

Treating Maternal HypertensionJames N. Martin, Jr., MD; Laurence E. Shields, MD; Maurice L. Druzin, MD

Alliance for Innovation in Maternal Health (AIM)February 2017

Maternal Mortality Rate California and United States 1999-2013

11.1

7.7

10.0

14.6

11.8 11.7

14.0

7.47.3

10.9

9.7

11.6

9.2

6.2

16.9

8.9

15.1

13.1

12.19.99.9

9.8

13.3

12.7

15.5 16.916.6

19.3

19.9

22.0

0.0

3.0

6.0

9.0

12.0

15.0

18.0

21.0

24.0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

California Rate

United States Rate

Mat

erna

l Dea

ths

per 1

00,0

00 L

ive

Birt

hs

HP 2020 Objective – 11.4 Deaths per 100,000 Live Births

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govonMarch 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March, 2015.

http://wonder.cdc.govon/

Cause of U.S. Maternal Mortality• CDC Review of 14 years of coded data: 1979-1992• 4024 maternal deaths• 790 (19.6%) from preeclampsia

MacKay AP, Berg CJ, Atrash HK. Obstetrics and Gynecology 2001;97:533-538

90% of CVA were from hemorrhage

Presenter

Presentation Notes

We have made no progress with regard to preventing maternal death from hemorrhagic cerebral vascular accidents.

CA-PAMR Final Cause of Death Among Preeclampsia Cases, 2002-2004 (n=25)

Final Cause of Death Number % Rate/100,000

StrokeHemorrhagicThrombotic

16142 12.5%

1.0

Hepatic (liver) Failure 4 16.0% .25

Cardiac Failure 2 8.0%Hemorrhage/DIC 1 4.0%Multi-organ failure 1 4.0%ARDS 1 4.0%

How Do Women Die Of Preeclampsia in CA?

4

64%

87.5%

Presenter

Presentation Notes

16 of the 25 women or 64% of the deaths were due to strokes, with 87.5% being hemorrhagic stroke. As we will see in the analysis of quality improvement opportunities, the greatest opportunity to prevent maternal deaths from preeclampsia is to prevent stroke. In order to to this it is imperative to recognize and appropriately treat systolic and diastolic hypertension in a timely manner.

Clinical Cause ofDeath

Chance to Alter Outcome (%) Strong/Good Some None Total N

Obstetric hemorrhage 14 5 1 20Deep vein thrombosis/

pulmonary embolism

10 9 1 20

Sepsis/infection 7 6 1 14Preeclampsia/eclampsia* 21(60) 14(40) 0 35Cardiomyopathy and other cardiovascular causes* 14 30 4 48

Cerebral vascular accident 3 4 9 16Amniotic fluid embolism 0 15 3 18All other causes of death 15 15 4 34Total (%) 84 98 23 205*

CA-PAMR Pregnancy-Related Deaths, Chance to Alter Outcome by Grouped Cause of Death; 2002-2005 (N=207)

* Two deaths lacked sufficient records to make determination (one from each cause of death).

Presenter

Presentation Notes

PREVENTABILITY, also known as Chance to Alter Fatal Outcome Overall 41% of the pregnancy-related deaths were determined by the CA-PAMR Committee to have had a good-to-strong chance of being prevented. When the chance to alter outcome was examined preeclampsia deaths, Tragically, all of these deaths were determined to have at least some chance to alter the outcome, and half of those were determined to have a strong-to-good chance to alter the outcome. 21 of the 35 cases of preeclampsia (60%). Of the 84 (41%) cases with a good-to-strong chance to alter the outcome, the Committee determined that one or more healthcare professional factors contributed in 54 deaths (95%), one or more health care facility factors contributed in 37 (65%) cases, and one or more patient factors contributed in 45 (79%) cases. The quality improvement opportunities suggested by the data include better management of hemorrhage and preeclampsia, and chronic conditions such as obesity. Data Source: CA PAMR, Pregnancy-Related Deaths; 2002-2005 (N=207).

Contributing Factor(at least one factor probably or definitely contributed)

PreeclampsiaN (%)

TOTALN (%)

OVERALL 25 (100%) 129 (89%)

PATIENT FACTORS 16 (64%) 104 (72%) Underlying significant medical conditions 8 (50%) 40 (39%)

Delay or failure to seek care 10 (63%) 27 (26%)

Lack of understanding the importance of a health event

9 (56%) 16 (15%)

HEALTHCARE PROFESSIONALS 24 (96%) 115 (79%)Delay in diagnosis 22 (92%) 62 (54%) Misdiagnosis 13 (54%) 36 (31%)

Use of ineffective treatment 19 (79%) 48 (42%)

Failure to refer or seek consultation 6 (25%) 26 (23%)

HEALTHCARE FACILITY 12 (48%) 72 (50%)

Factors Contributing to Pregnancy-Related Deaths CA-PAMR 2002-2004

Presenter

Presentation Notes

Contributing factors R/T the healthcare providers involved in the care of the patient were identified in 96% of the cases and of these, the factors which definitely or probably contributed to the fatal outcome were Delay in Dx, ineffective tx and misdiagnosis. At least 1 healthcare facility factor was identified in 12 (48%) of the deaths and the most frequent factors that contributed to the deaths include: inadequate staff and lack of continuity of care.

Reaffirmed 2012

BP Treatment Recommendations

Systolic≥ 160

Diastolic ≥ 110

Repeat BP and treat within 60 minutes

(ideally ASAP)

≥155 ≥105-110 Alternative triggers*

Chronic HTN - Gestational HTN - Preeclampsia - Severe Preeclampsia

These recommendations apply to all forms of hypertension in pregnancy and postpartum:

* Based on Martin 2005: Martin J, Thigpen B, Moore R, et al.. Obstet Gynecol 2005; 105(2):246-254. 45

Presenter

Presentation Notes

Treatment should be initiated for blood pressures that are ≥160 mm Hg systolic or 105-110 mm Hg diastolic. Alternative triggers that have been discussed in Martin’s study (2005), suggest that treatment should be initiated at a lower threshold of 155/105 if the primary goal is to reduce maternal intracranial hemorrhage, which remains the leading cause of death from preeclampsia.4

Ref: AJOG, Month 2016, In Press

Rate of Eclampsia/1000 Births and SMM/100 Births

10

1.16

0.820.62

2.4

2.11.9

0.0

0.5

1.0

1.5

2.0

2.5

Baseline Phase I Phase II

Eclampsia SMM Delta 20.1%p<0.01

Delta 46.5%P=0.02

Treatment of elevated blood pressure, give magnesium sulfate, early postpartum follow-up

• Acute-onset, severe hypertension ,160 systolic, OR 110 diastolic,that is accurately measured using standard techniques and is persistent for 15 minutes or more is considered a hypertensive emergency. (repeat and treat)

• First-Line Therapy – Recommendations• IV labetalol or/and hydralazine• Evidence available suggests that oral Nifedipine,10 mg, also may be considered as a

first-line therapy.• Treatment within 30-60 minutes. (repeat and treat)

Magnesium Sulfate

• Primary effect is via CNS depression• Improves blood flow to CNS via small vessel

vasodilation• Blood pressure after magnesium infusion: 6 gm loading then 2 gm/hr.

sBPmm Hg

sBP30 min

sBP120 min

dBPmm Hg

dBP30 min

dBP120 min

Mild Group

145±10

143±13

141±14

87±10

79±9

82±9

Belfort M, Allred J, Dildy G. Magnesium sulfate decreases cerebral perfusion pressure in preeclampsia.Hypertens Pregnancy. 2008;27(4):315-27.

Magnesium sulfate should not be considered a antihypertensive medication

For Additional resources go to:http://safehealthcareforeverywoman.org

Or contact [email protected]

Thank you.

http://safehealthcareforeverywoman.org/

mailto:[email protected]

treating maternal hypertension hp2020 objective use the same codes. u.s. maternal mortality data is...

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