PQCNC 2014 Annual Meeting Arthur Ollendorff

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Conservative

Management of

Preeclampsia

(C-MOP)

PQCNC Annual Meeting

January 7, 2014



Arthur Ollendorff, MDMAHEC OB/GYN Specialists

Asheville, NC

Clinical Professor of OB/GYN

University of North Carolina SOM

[email protected]

mailto:[email protected]

mailto:[email protected]



Outline for Afternoon

2:00-2:45 Elliott Mane

Quality Improvement in Preeclampsia

2:50-3:10 Kathy & Clark Ellis

The Family’s Perspective

3:10-3:35 Arthur Ollendorff

Classification of Hypertension in Pregnancy

3:45-3:55 Break3:55-4:40 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 accountthe 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 PregnancyTaskforce.



My Favorite Definition of EBM

Evidence-Based Medicine is critical

appraisal of the literature applied through

the clinician’s experience and judgment



The Modified Evidence Pyramid

Quality of Evidence

High

Low Individual

Patient

Large Populations

Applicability



“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 withsuperimposed preeclampsia




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 hoursapart 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




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 renaldisease)

Pulmonary edema

New-onset cerebral or visual disturbances




What Else Has Changed

Preeclampsia can exist without

proteinuria

Preeclampsia with severe featurescan be diagnosed with any severe

feature

• Severe Gestational Hypertension no

longer exists




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 featurespresent

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 LFTor symptoms

Renal insufficiency

Pulmonary edema Cerebral or visual disturbances




A Stepwise Approach

3. Patient with new onset elevated

blood pressure and no severe

features. Perform 24 hour urine forprotein.

< 300 mg - classify as gestational

hypertension

≥ 300 mg - classify as preeclampsia

without severe features






ACOG’s Guidance on

Clinical Conundrums

Subjective symptoms that define

severe features

Diagnosing chronic hypertension withsuperimposed 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




Chronic hypertension with

superimposed preeclampsia

Superimposed preeclampsia should

be considered when there is

a sudden increase in BP that waspreviously well controlled

sudden, substantial and sustained

increase in proteinuria

development of severe features




Superimposed Preeclampsia

“Clinicians should recognize that there

is often ambiguity in the diagnosis of

superimposed preeclampsia and that

the clinical spectrum of disease isbroad”

“Increased surveillance but not

intervention (e.g. delivery) iswarranted even if the diagnosis is

suspected and not definitive”




When In Doubt Use This

Resource




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

PQCNC 2014 Annual Meeting Arthur Ollendorff

Documents