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24-WD-SPEC-431-Manage Hypertension Blog - 03. Creative-V1-MD (1)

A Clinical Development Plan to Manage Hypertension During Pregnancy

October 9th, 2024
October 9th, 2024

Hypertensive disorders of pregnancy occur in 8-10% of of pregnancies in the United States. Patients with hypertension during pregnancy have increased morbidity and mortality due to subsequent cardiovascular disease, cardiomyopathy, and pulmonary hypertension. Furthermore, these conditions are leading contributors to premature birth, leading to increased morbidity and mortality within the neonatal population.

The Significance of Managing Hypertension During Pregnancy

In 2021, The Joint Commission established new standards of hospital care for hypertensive disorders of pregnancy for all birthing facilities, requiring organizations to implement a standardized clinical development plan for hypertension management. Standardized education and treatment, like that provided in HealthStream’s Quality OB toolkit, helps hospitals meet The Joint Commission requirements, improve maternal and fetal health outcomes, and give providers the tools they need to make quick decisions while treating this at-risk population.

Pregnancy Hypertension 101

Hypertensive disorders in pregnancy encompass four related presentations: chronic hypertension, gestational hypertension, preeclampsia, and eclampsia.

  • Chronic hypertension is high blood pressure (140/90 millimeters of mercury [mm/Hg] or higher) occurring before the start of pregnancy or within 20 weeks of gestation.
  • Gestational hypertension is a systolic blood pressure of 140 mm/Hg, a diastolic blood pressure of 90 mm/Hg or more, or both on two occasions at least four hours apart after 20 weeks gestation in an individual with previously normal blood pressure.
  • Severe hypertension is a measurement of systolic blood pressure of 160 mm/Hg or greater, a diastolic blood pressure of 110 mm/Hg or greater, or both, persisting over a period of 15 minutes.
  • Preeclampsia is maternal blood pressure measurements of 140-159 mm/Hg systolic or 90-109 mm/Hg diastolic on two readings taken four hours apart, proteinuria greater than 300 mg in 24, or a protein to creatinine ratio greater than 0.3 on an untimed urine specimen. Preeclampsia may also be superimposed on a patient with chronic hypertension.
  • Preeclampsia with severe features includes changes that define preeclampsia plus one or more of the following findings:
    • Blood pressures within the severe range of 160 mm/Hg or 110 mm Hg/mm on two occasions at least four hours apart
    • Visual disturbances or cerebral concerns, such as persistent headache or blurred vision
    • Thrombocytopenia (platelet count < 100,000/mm3)
    • Pulmonary edema
    • Renal dysfunction (serum creatinine > 1.1 mg/dL or a 50% increase over baseline value)
    • Hepatic dysfunction (elevated AST and ALT > 2 times the upper limit of the reference range, severe and persistent epigastric, or right upper quadrant pain)

Only one of these findings needs to be present for the diagnosis of preeclampsia with severe features.

  • Eclampsia is defined by the occurrence of a grand mal seizure or onset of coma with no other known cause in a pregnant person with preeclampsia.
  • HELLP syndrome is a form of preeclampsia in which blood studies reveal AST and ALT of twice the upper limit of reference range, elevated serum bilirubin, thrombocytopenia, and evidence of hemolysis (LDH >600 and decreased haptoglobin; abnormal blood smear). HELLP syndrome may mimic symptoms of gastroenteritis or gallbladder disease.

It is imperative that every clinical setting with the potential to serve pregnant and postpartum people creates a clinical development plan for hypertension management. Uniform care ensures that all individuals receive timely, quality treatment regardless of background.

Steps to Create and Implement a Clinical Development Plan for Hypertension Management

In the Severe Hypertension in Pregnancy patient safety bundle, the Alliance for Innovation on Maternal Health suggests implementing a clinical development plan using the Readiness, Recognition, Response, and Reporting approach.

Step 1: Readiness

Recommended medications to treat pregnancy hypertension should be quickly accessible within obstetric units, the emergency department, and any other areas where peripartum treatment occurs. Providing education, drills, and debriefs before implementing new standardized protocols will solidify new information on recognizing and treating this patient population.

Step 2: Recognition

Every individual who presents with symptoms of hypertension, preeclampsia, or eclampsia necessitates lab evaluation and early medical management for severe range hypertension while assessing the overall clinical picture. The recognition phase of the clinical development plan for hypertension management also includes screening every pregnant or postpartum individual’s medical, mental, and behavioral health needs.

Step 3: Response

Standardized responses to individuals presenting with hypertensive disorders of pregnancy must include the following:

  • Monitoring blood pressure and notifying providers of elevated readings
  • Initiating antihypertensive medications and magnesium sulfate therapies
  • Escalating patient care as appropriate

HealthStream’s solutions transform recommendations from The Joint Commission and the American College of American College of Obstetricians and Gynecologists into easy-to-use tools, guiding providers to deliver the most up-to-date and safest care possible.

Step 4: Reporting

Case reviews identify opportunities for improvement and assess an institution’s adherence to policies and procedures. Reviews should be timely and nonpunitive. Report consistent findings to the predetermined administration.

Continuous Improvement of Maternal and Fetal Health Through Effective Hypertension Management

Creating standardized care delivery takes time, yet it results in faster treatment and improved outcomes. Healthcare professionals possess the ability to directly affect maternal and fetal health. Having a predetermined strategy to care for patients with hypertensive disorders of pregnancy gives the healthcare team the tools needed to act swiftly and ensure the best care possible.

HealthStream’s solution for Quality OB care includes staff education and practice recommendations that align with these requirements. It allows teams to create a clinical development plan with the goal of achieving zero serious safety events in obstetric care areas.

 

 

References
Alliance for Innovation on Maternal Health (AIM). (2022). Severe hypertension in pregnancy. https://saferbirth.org/psbs/severe-hypertension-in-pregnancy/
California Maternal Quality Care Collaborative. (2021). Hypertensive disorders of pregnancy toolkit. rces-tool-kits/tohttps://www.cmqcc.org/resouolkits/HDP
Gestational hypertension and preeclampsia: ACOG practice bulletin, number 222. (2020). Obstetrics & Gynecology, 135(6), e237-e260. doi: 10.1097/AOG https://journals.lww.com/greenjournal/abstract/2020/06000/gestational_hypertension_and_preeclampsia__acog.46.aspx
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