Morbidity and Mortality Conference

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1 Morbidity and Mortality Conference Garrett Feddersen 02/25/15 Case: Brief Admission HPI TM is a 31 year old female continuity OB patient She has a complex OB history Good prenatal care, started following with our clinic at 20 weeks Presents in office at 39w5d for regular OB visit. She has no concerns, feels good. HPI, continued Case: OB Hx: G6P spontaneous abortion at 8 wks 1 delivered at 36 weeks 3 term were all induced for preeclampsia All vaginal deliveries 1 was delivered in the backseat of a car on the way to AMH PMH asthma, HSIL w/ LEEP PSH - none FH nothing pertinent SH Very poor social support, DFR had been involved with all of her pregnancies. Medications Prenatal vitimin Allergies - none 1

2 Case: Physical exam Vitals BP156/110, P85, R16, 100% ra Fundal height 39 cm, fetal HR 132 Rest of PE entirely normal BP at last 3 visits: 143/96, 138/95, 114/80 slowly creeping up Cervix at previous visit was 3-4 cm All prenatal labs were normal. Urine protein continually negative Ddx Preeclampsia is obviously a concern Pregnancy-induced HTN Chronic HTN Clinical decisions Given her increasing blood pressures, history of preeclampsia with other pregnancies, and her gestational age of 39 5/7, we elected to send her in for induction. Called AMH OB: No beds available, but have 6 discharges this AM, will be no later than noon or 1 PM. If it is emergent we could bring her in to triage and start induction there. After discussion, we said we can wait until noon. Date/Time Timeline of Events Clinical Status/ change in status 0830 Patient seen in clinic 0930 Call to AMH OB, told would have a bed by 12 or 1 PM. Patient phone number confirmed by me and nursing, sent home with instructions to head in as soon as phone call Called AMH OB, still no beds 1330 Called AMH, still no beds After multiple phone calls, we finally have a bed. AMH OB and myself attempt to call pt bad # 1600 Our ingenious clinic nurses call pt s mother, she goes to pt s house 1830 Patient finally arrives at AMH 1730 Induction actually started cm dilated 2231 Called to bedside 2239 Healthy baby boy born, APGARS 9 and 9, 7 lbs, 3.6 oz Tubal ligation the next day Postpartum She was still hypertensive and was given one dose of hydralazine and started on amlodipine 5 mg daily. She stayed on amlodipine for 2 weeks, her BP normalized, and we were able to discontinue. 2

3 Adverse events/outcomes triggering case presentation Hypertension and Preeclampsia Case Yes No Unexpected death Medical or surgical complication Delay in care Delay in Diagnosis Prolonged medical care in setting of poor prognosis Other The National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy has defined four categories of hypertension in pregnancy: chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension. Eclampsia BP >140/90, chronic if before 20 wks Chronic Hypertension If present before 20 wks or after 12 weeks postpartum Treatment required for severely elevated blood pressure (150 to 180/100 to 110 mm Hg); treatment of mild to moderate chronic hypertension does not improve neonatal outcomes or prevent superimposed preeclampsia IUGR and preeclampsia are biggest risks Methyldopa, labetalol, and nifedipine IV labetalol and hydralazine for emergencies Gestational hypertension 50% of women diagnosed with gestational hypertension between 24 and 35 weeks develop preeclampsia. Women who progress to severe gestational hypertension based on the degree of blood pressure elevation have worse perinatal outcomes than do women with mild preeclampsia, and require management similar to those with severe preeclampsia. Preeclampsia Hypertension and proteinuria after 20 weeks of gestation. The diagnostic threshold for proteinuria is 300 mg in a 24-hour urine specimen. A 24-hour determination is most accurate because urine dipsticks can be affected by variable excretion, maternal dehydration, and bacteriuria. A random urine protein/creatinine ratio of less than 0.21 indicates that significant proteinuria is unlikely with a negative predictive value of 83 percent Generalized edema is often present BUT IS NOT A DIAGNOSTIC CRITERIA. 3

4 Expectant Management of Mild Preeclampsia Maternal monitoring Measure blood pressure twice weekly Obtain laboratory tests weekly: CBC, platelet count, ALT, AST, LDH, uric acid, creatinine Assess for proteinuria: screen with dipstick or spot protein/creatinine ratio and obtain periodic 24-hour urine collections Fetal monitoring Obtain nonstress test twice weekly Measure amniotic fluid index once or twice weekly Biophysical profile may be done weekly in place of one of the twice-weekly nonstress tests and amniotic fluid index Perform ultrasonography for fetal growth every three to four weeks Treatment: Prevention through routine supplementation with calcium, magnesium, omega-3 fatty acids, or antioxidant vitamins is ineffective. BUT Calcium supplementation reduces the risk of developing preeclampsia in high-risk women and those with low dietary calcium intakes. Low-dose aspirin (75 to 81 mg per day) is effective for women at increased risk of preeclampsia. Delivery is the only cure for preeclampsia. Decisions regarding the timing and mode of delivery are based on a combination of maternal and fetal factors. Fetal factors include gestational age, evidence of lung maturity, and signs of fetal compromise on antenatal assessment. Patients with treatment-resistant severe hypertension or other signs of maternal or fetal deterioration should be delivered within 24 hours, irrespective of gestational age or fetal lung maturity. Fetuses older than 34 weeks, or those with documented lung maturity, are also delivered without delay Severe Preeclampsia Criteria Blood pressure 160 mm Hg systolic or 110 mm Hg diastolic on two occasions at least six hours apart during bed rest Proteinuria 5 g in a 24-hour urine specimen or 3+ or greater on two random urine specimens collected at least four hours apart Any of the following associated signs and symptoms: Cerebral or visual disturbances Epigastric or right upper quadrant pain Fetal growth restriction Impaired liver function Oliguria < 500 ml in 24 hours Pulmonary edema Thrombocytopenia HELLP Syndrome Variant of severe preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelet count. HELLP syndrome occurs in up to 20 percent of pregnancies complicated by severe preeclampsia The clinical presentation of HELLP syndrome is variable; 12 to 18 percent of affected women are normotensive and 13 percent do not have proteinuria. At diagnosis, 30 percent of women are postpartum, 18 percent are term, and 52 percent are preterm. 4

5 Room for improvement I should have pushed harder for a room or at the very least for her to be brought in to triage to start induction there Lots of communication issues Given her risk factors with prior deliveries, she should have been initiated on ASA therapy and calcium therapy. Perhaps earlier intervention the week prior, though her BP was in the mild category. Clinical Pearls from the AAFP Magnesium sulfate is more effective than diazepam or phenytoin in preventing recurrent eclamptic seizures. (A) In women without end-organ damage, chronic hypertension in pregnancy does not require treatment unless the patient's blood pressure is persistently greater than 150 to 180/100 to 110 mm Hg. (C) Calcium supplementation decreases the incidence of hypertension and preeclampsia, respectively, among all women (A) Low-dose aspirin (75 to 81 mg daily) has small to moderate benefits for the prevention of preeclampsia, the benefit is greatest in women at highest risk (B) For women with mild preeclampsia, delivery is generally not indicated until 37 to 38 weeks of gestation and should occur by 40 weeks. Magnesium sulfate is the treatment of choice for women with preeclampsia to prevent eclamptic seizures and placental abruption (A) Intravenous labetalol or hydralazine may be used to treat severe hypertension in pregnancy because neither agent has demonstrated superior effectiveness. (B) For managing severe preeclampsia between 24 and 34 weeks of gestation, the data are insufficient to determine whether an interventionist approach is superior to expectant management. Expectant management, with close monitoring of the mother and fetus, reduces neonatal complications and stay in the newborn intensive care nursery. (B) Questions and comments 5