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Hypertension in Pregnancy Care Process Model Minnesota Perinatal Quality Collaborative Hypertension in Pregnancy Care Process Model HYPERTENSION IN PREGNANCY CARE PROCESS MODEL Resources for Providers, Nurses, and Health Care Consumers Disclaimer: Applicability of all information within is subject to change based on current literature and was last accurate as of 7.24.2020. Document will be reviewed every six months. Page | 1 MNPQC Subcommittee for Maternal Hypertension Approved for use 7.24.20 MinnesotaMinnesota Perinatal Perinatal Quality Quality Collaborative Collaborative HypertensionHypertension in Pregnancyin Pregnancy Care Care Process Process Model Model KEY POINTS Acute onset, severe hypertension in Obstetrics defined: • SBP ≥160 and/or • DBP ≥110 • And persistent for 15 minutes or longer. • Treatment with first line agents occurs withing 30- 60 minutes of confirmed severe hypertension • First line antihypertensives include: • IV labetalol • IV hydralazine or WHAT’S INSIDE: • Oral, short acting nifedipine (When IV access is Topic: Page not present) Key Points……………….………………….........2 • Minimum intervals between antihypertensives are ACOG Definitions………..…………...............3 different: Blood Pressure Measurement.............4-6 • IV hydralazine and nifedipine Preeclampsia Early Recognition Tool….7 • 20 minutes or greater intervals Nursing Assessment..…..……...….…….8-9 • IV labetalol Hypertensive Emergency……………….…10 • 10 minutes or greater interval Antenatal Management……………….…..11 Medications……………………………….…….12 • Cardiac monitoring is not required; Can be Delivery Indications………………………….13 considered for patients with high risk morbidities ACOG 767………………………………………..14 (such as coronary artery disease) FAQ…………………………………………..........15 Algorithms……………………….…….…..16-21 • After Acute antihypertensive therapy is initiated Consumer Education…….……….…...22-26 • BP every 10 minutes until Consumer Resources……………………….27 • SBP<160 AND Bands……………………….…………………….28 • DBP<110 for 60 minutes How to Implement……………………….….29 References………………….………..……30-31 • Patient care team should have individualized action plan for patients with persistent hypertension Work Group Members.……………………..32 despite antihypertensives and eclampsia • Discharge guideline and planning: • SBP<150 and DBP <100 for 24 hours • 72 hours inpatient post-partum or equivalent outpatient monitoring • No IV Antihypertensives for 24 hours • Stable on oral antihypertensive for 24-48 hours • Consider BP cuff prescription, if covered by insurance • Follow-up appointment within 24 hours to 1 week • Long term implications and care • Internal Medicine follow up Page | 2 MNPQC Subcommittee for Maternal Hypertension Approved for use 7.24.20 Minnesota Perinatal Quality Collaborative Hypertension in Pregnancy Care Process Model ACOG Definitions Severe hypertension Systolic ≥160 and/or diastolic ≥110 in the prenatal, intrapartum or postpartum periods. Hypertensive emergency “Acute-onset, severe hypertension that is accurately measured using standard techniques and is persistent for 15 minutes or more” Gestational hypertension New onset hypertension (SBP ≥140 and/or DBP ≥90 on at least two occasions at least 4 hours apart) at ≥20 weeks of gestation in the absence of proteinuria or new end-organ dysfunction. Return to normotensive pressures postpartum https://journals.lww.com/mcnjournal/Fulltext/2019/05000/Gestational_Hypertension_an d_Preeclampsia.7.aspx Wisner, K. (2019). Gestational Hypertension and Preeclampsia MCN: The American Journal of Maternal/Child Nursing: May/June 2019 - Volume 44 - Issue 3 - p 170 doi: 10.1097/NMC.0000000000000523 Gestational hypertension with severe features “Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher) should be diagnosed with preeclampsia with severe 5 features .” Preeclampsia without severe features New onset hypertension (SBP ≥140 and/or DBP ≥90 on at least two occasions at least 4 hours apart) at ≥20 weeks of gestation with proteinuria or new end-organ dysfunction. Proteinuria: ≥300 mg protein on 24 hr. collection, protein/creatinine ratio of ≥ 0.3 or dipstick with 2+protein Preeclampsia with severe features SBP ≥160 and/or DBP ≥110 on two occasions at least 4 hours apart (unless antihypertensive therapy is initiated before this time) Thrombocytopenia defined as platelets <100,000 Impaired liver function defined as twice the upper limit normal concentration Severe, persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses Renal insufficiency defined as creatinine >1.1 mg/dL or a doubling of the serum creatinine in absence of other renal disease Pulmonary edema New-onset headache unresponsive to medication and not accounted for by alternative diagnoses Visual disturbances Page | 3 MNPQC Subcommittee for Maternal Hypertension Approved for use 7.24.20 Minnesota Perinatal Quality Collaborative Hypertension in Pregnancy Care Process Model Blood Pressure Measurement A Standardized Approach: I. Equipment A. Cuff Placement/position 1. Position the cuff around the upper arm so: a. The lower boarder of the cuff is 2-3 cm/~1 inch above the antecubital fossa to best auscultate the brachial artery b. The artery mark on the cuff is aligned with the brachial artery c. Place the center of the bladder over the brachial artery pulse d. Forearm method: i. place the center of the bladder to be over and between the brachial artery and radial artery pulses B. Cuff Size 1. In all cases: a. Educate and include the patient in how her BP is measured; b. Encourage her to speak up to other providers about the best methods to obtain her BP, to aid in consistency of practice 2. Wrong sized cuff a. May lead to misclassification as hypertensive b. Unnecessary concern c. Unnecessary therapy 3. Recommended cuff size per age group/size: a. Small-size adult (arm circumference <23 cm/9 in) – 12 cm/4.7 in x 18 cm/7in b. Average-size adult (arm circumference <33 cm/13in) – 12 cm/4.7 in x 26cm/10.2 in c. Large-size adult (arm circumference <50 cm/19.6 in) – 12 cm/4.7in x 40 cm/15.7 in 4. Cuff size selection: a. Wide enough to encircle 80% of the upper arm b. Long enough to be fastened securely i. wrong sized cuff produces inaccurate readings ii. even when the cuff doesn’t come off/release during inflation c. Consider using a pediatric cuff for patients with small extremities C. Upper-arm circumference >34cm 1. Consider width and arm length a. If cuff width is >80% of the arm length, measurements will be inaccurate, may require a narrower, but longer cuff b. Large adult cuff c. Thigh cuff D. Upper-arm circumference >50cm 1. Be consistent in the location, technique and cuff size when obtaining a BP 2. Establish a size or method that works for the individual 3. If no other cuffs fit the upper arm appropriately, use the forearm a. Use appropriately sized cuff to fit the forearm as previously described b. Arm to be dependent at the level of the heart c. Can be obtained electronically (preferred) or d. Obtain via Systolic/palpation by palpating for radial pulse, after cuff is inflated, feeling for return of pulse. This provides only the Systolic measurement i. accuracy of these methods has not been validated, but they provide a general estimate of the systolic blood pressure. Page | 4 MNPQC Subcommittee for Maternal Hypertension Approved for use 7.24.20 Minnesota Perinatal Quality Collaborative Hypertension in Pregnancy Care Process Model Blood Pressure Measurement A Standardized Approach: II. Methods of Measurements: A. Mercury sphygmomanometers have historically been the standard in healthcare settings. 1. Due to toxicity of mercury and environmental hazards, mercury sphygmomanometers are now rarely used. B. Manual Non-Mercury containing devices: 1. Measurement technique requires use of a stethoscope 2. Relies on an auscultator approach 3. Manual office blood pressure measurements are subject to observer error 4. Visual number recognition and manual recording can lead to bias for specific numbers 5. Bias decreases blood pressure measurement precision and accuracy C. Electronic/Automated Devices in the healthcare setting: 1. Studies demonstrate similar readings using automated office blood pressure devices when compared with ambulatory blood pressure measurements and a stronger correlation than that with manual office readings a. See 3d, without human factors. D. Home blood pressure monitoring. (see page 26 for consumer resources) 1. Patients are responsible for: a. Performing their own blood pressure measurements b. Maintaining a log c. Reporting data back to their physician’s office i. This method has been shown to provide real life measurements of what the patient experiences in their own environment ii. Patients doing at home monitoring tend to be more compliant with treatment recommendations iii. Patient education on technique is required III. Patient Considerations for Measuring BP: A.A.A. Outpatient patient technique: (With human operator performing the measurement) 1. Seated in a chair with back support 2. Feet flat on the floor 3. No crossed legs 4. At rest for 5 minutes 5. No conversation during measurement 6. Measurement arm is supported on flat surface at mid sternal level. 7. Appropriate size cuff B. In-Patient technique: 1. Sitting or semi-reclining position with back supported. 2. If current position is laying down, then take BP as the patient is 3. Feet flat on the floor if sitting 4. No crossed legs 5. No conversation
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