Hypertension in Pregnancy Care Process Model

Minnesota Perinatal Quality Collaborative

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.

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Minnesota Perinatal Quality Collaborative Minnesota Perinatal Quality 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

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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

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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 during measurement 6. Measurement arm is supported on flat surface at mid sternal level. 7. Appropriate size cuff

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Blood Pressure Measurement A Standardized Approach: C. Considerations in all settings: 1. muscle contraction can result in inaccurately high DBP measurement 2. measurements can be inaccurately low if arm is elevated above the heart level (effect of gravity) and inaccurately high if the arm is below the heart level. 3. The US Preventative Service Task Force recommends recording the mean of the 2 measurements taken 5 minutes apart 4. This is in accordance with newly published clinical practice guidelines advising 2 to

3 measurements taken at 2 to 3 separate time points for assessment and management of hypertension. IV. Without the Human operator in the room: B. All of the above measures, except no need to wait 5 minutes for rest. C. Patient left alone in the room D. Automated readings set to repeated measurements at 1-minute intervals for 5- to 7-minutes. 1. Removal of the human operator element decreases the potential for the white coat effect and number recording bias. V. Never reposition patient with intent to obtain a lower BP; it provides a false readings. VI. Contraindications for Measuring BP of a limb: A. Being used for IV fluid infusion

B. With an arteriovenous (AV) shunt of fistula

C. On the same side of the body as mastectomy or axillary surgery D. With evidence of disease or trauma VII. Other Resources: B. https://www.youtube.com/watch?v=Za9RdBHpeAI C. https://www.preeclampsia.org/the-news/53-health-information/614-your-blood-pressure-know- the-basics

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Early recognition of gestational hypertension and preeclampsia can lead to improved outcomes with timely intervention. The Minnesota Hospital Association recommends use of an early recognition tool for preeclampsia. PREECLAMPSIA EARLY RECOGNITION TOOL (PERT)

NORMAL WORRISOME SEVERE ASSESS (GREEN) (YELLOW) (RED)

Agitated/confused Awareness Alert/oriented Drowsy Difficulty Unresponsive speaking

Mild headache Unrelieved Headache None Nausea, vomiting headache Temporary Vision None Blurred or impaired blindness

Systolic BP (mm HG) 100-139 140-159 ≥160 Diastolic BP (mm HG) 50-89 90-105 ≥105 HR 61-110 111-129 ≥130

Respiration 11-24 25-30 <10 or >30 SOB Absent Present Present O2 Sat (%) ≥95 91-94 ≤90

Nausea, vomiting Nausea, vomiting Pain: Abdomen RED = SEVERE or Chest None Chest pain Chest pain Abdominal pain Abdominal pain Trigger: 1 of any type TO DO Category I listed below Category II IUGR Category III Fetal Signs Reactive NST Non-reactive NST Immediate evaluation 1 of any type Transfer to higher acuity level Urine Output ≥50 30-49 ≤30 (in 2 hrs.) 1:1 staff ratio (ml/ hr. ) Consider Neurology consult Proteinuria Awareness CT Scan (Level of Headache R/O SAH/intracranial proteinuria is not Visual > +1** hemorrhage an accurate ≥300mg/24 hours predictor of Trace Labetalol/hydralazine in 30 pregnancy min outcome) BP In-person evaluation Magnesium sulfate loading or Platelets >100 50-100 <50 maintenance infusion

AST/ALT <70 >70 >70 Chest Pain Consider CT angiogram Creatinine <0.8 0.9-1.1 >1.2 O2 at 10 L per rebreather DTR +1 Respiration Magnesium mask Respiration 16- Depression of Respiration <12 SOB Sulfate R/O pulmonary edema 20 patellar reflexes O2 SAT Toxicity Chest x-ray Page | 7 MNPQC Subcommittee for Maternal Hypertension Approved for use 7.24.20

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RECOMMENDATIONS, Nursing Assessment

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RECOMMENDATIONS, Nursing Assessment

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RECOMMENDATIONS, Emergency Management

HYPEHYPERRRRTENSIVETENSIVE EEEMEMMMEEEERRRRGENCYGENCY AND AAAPAPPPPPRRRROPRIOPRIOPRIAAAATETETETE MEDMEDIIIICCCCAAAATIONSTIONS

For SBP ≥ 160 AND/OR DBP ≥ 110, recheck BP in 15 minutes.

If repeat SBP ≥160 AND/OR DBP ≥110: 1) Notify provider

2) Administer antihypertensive ASAP (expectation is <60 minutes, sooner is If repeat SBP < 160 AND optimal) DBP < 110: IV labetalol (minimum 10-minute interval between doses) 1) Check blood pressure q30 IV hydralazine (minimum 20-minute min for 1 hr. interval between doses)

PO nifedipine (short acting) (minimum

20-minute interval between doses 2) If BP still at goal, return to vital signs frequency per 3) Check blood pressure q10 min until parameters in tables 1 & 2 goal SBP <160 AND DBP <110 for 1 hr.

4) Once at goal for 1 hour, check BP q15 min for 1 hr., q30 min for 1 hr., hourly for 4 hr. then return to vitals per parameters in boxes 1 & 2

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RECOMMENDATIONS, Management

https://journals.lww.com/mcnjournal/Fulltext/2019/05000/Gestational_Hypertension_and_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

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RECOMMENDATIONS, Medication:

Labetalol Hypertensive Medication Administration

 Mechanism: Combined α & β blocker which leads IV versus Oral (po) to arteriolar dilation and decreased heart rate.

 IV Push: Administer dose IV push 10mg/minute. IV Labetalol IV  Repeat doses may be given at minimum of 10- • Onset: 2-5 min Hydralazine minute intervals Peak: 5 min • Onset: 5-20 min  Maximum dose: 220-240 mg/24 hours.  Side effects: hypotension, dizziness, nausea Peak: 15- 30 min  Contraindications: Asthma, CHF, cocaine use, methamphetamine use. Beta blocker use in PO Labetalol: PO patients using cocaine or methamphetamine • Onset: 20 min-2 Nifedipine may result in an exaggerated decrease in blood pressure that is difficult to manage. hrs. • Onset: 5-20 min* Peak: 1-4 Peak: 30-  Consider alternative agent if maternal HR <60 Hydralazine hrs. 60 min  Mechanism: arteriolar dilation *PO, not sublingual nifedipine onset of  IV Push: Administer dose IV push 5mg/minute.  Repeat doses may be given at minimum 20-minute action is 15-30 minutes depending upon the source. intervals.  Caution: Administration at intervals shorter than 20 minutes may result in severe hypotension.  Maximum dose: 100mg/24h, ACOG recommends alternative medication  Side effects: tachycardia, headache, delayed  First line therapy for acute maternal hypotension, fetal bradycardia and rarely, treatment of critically elevated BP epigastric pain in pregnant women (160/105-110  Contraindications: coronary artery disease; Not mm Hg) are: compatible with LR, flush line with normal saline o IV labetalol or hydralazine before and administration. Nifedipine  Acute treatment needed WITHOUT  Mechanism: calcium channel blocker

 Dosing: 10 - 20 mg every 20-30 minutes as needed IV access: for hypertensive emergency up to 3 doses o Oral nifedipine (10 mg). May  Side effects: flushing, headache, dizziness, repeat in 20-30 minutes. PO nausea, edema, heartburn nifedipine appears equally as  Contraindications: hypersensitivity to medication efficacious as IV labetalol in Reportable Conditions correcting severe BP elevations.  Notify provider for: o  Diastolic blood pressure less than 80 or greater Oral labetalol would be expected than 105-110 following medication to be less effective in acutely administration. lowering the BP due to the  Category II or III fetal heart rate tracing slower onset to peak and thus following antihypertensive administration. should be used only if nifedipine  Sustained maternal heart rate less than 50 bpm is not available in a patient or greater than 120 bpm during or within 30 without IV access. minutes following medication administration.

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Delivery Indications and Timing:

Table 5: Delivery indications by Gestational age hypertensive condition 1, 2 (weeks) Chronic hypertension: isolated, controlled, no medications 38 0/7 – 39 /67 Chronic hypertension: isolated, controlled, with medications 37 0/7 – 39 6/7 Chronic hypertension: frequent medication adjustments 36 0/7 – 37 6/7

Gestational hypertension, no severe-range 37 0/7 or at time of blood pressure diagnosis if later Gestational hypertension with severe-range 34 0/7 weeks or at time of blood pressures diagnosis if later Preeclampsia without severe features 37 0/7 or at time of diagnosis if later Preeclampsia with severe features: after fetal 34 0/7 weeks or at time of viability with stable maternal and fetal diagnosis if later conditions (includes superimposed) Preeclampsia with severe features: after fetal viability with unstable maternal or fetal Soon after maternal conditions stabilization (includes superimposed and HELLP) Preeclampsia with severe features before Soon after maternal viability stabilization

Note: eclampsia was not included in this committee opinion, but delivery should be soon after maternal stabilization.

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ACOG Committee Opinion Number 767 (replaces 692, 09-2017) Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period

The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:  Introducing standardized, evidence-based clinical guidelines for the management of patients with preeclampsia and eclampsia has been demonstrated to reduce the incidence of adverse maternal outcomes.  Pregnant women or women in the postpartum period with acute-onset, severe systolic hypertension; severe diastolic hypertension; or both require urgent antihypertensive therapy.  Close maternal and fetal monitoring by a physician and nursing staff are advised during the treatment of acute-onset, severe hypertension.  After initial stabilization, the team should monitor blood pressure closely and institute maintenance therapy as needed.  Intravenous (IV) labetalol and hydralazine have long been considered first- line medications for the management of acute-onset, severe hypertension in pregnant women and women in the postpartum period.  Immediate release oral nifedipine also may be considered as a first-line therapy, particularly when IV access is not available.  The use of IV labetalol, IV hydralazine, or immediate release oral nifedipine for the treatment of acute-onset, severe hypertension for pregnant or postpartum patients does not require cardiac monitoring.  In the rare circumstance that IV bolus labetalol, hydralazine, or immediate release oral nifedipine fails to relieve acute-onset, severe hypertension and is given in successive appropriate doses, emergent consultation with an anesthesiologist, maternal–fetal medicine subspecialist, or critical care subspecialist to discuss second-line intervention is recommended.  Magnesium sulfate is not recommended as an antihypertensive agent, but magnesium sulfate remains the drug of choice for seizure prophylaxis for women with acute-onset severe hypertension during pregnancy and the postpartum period. Starting magnesium should not be delayed in the setting of acute severe hypertension; it is recommended regardless of whether the patient has gestational hypertension with severe features, preeclampsia with severe features, or eclampsia.

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FAQ’s

Treatment for Acute-onset Severe Hypertension during Pregnancy and the Postpartum period by: Dr. Elliott Main, AIM Implementation Director

Is there worry about fetal effects of treattreatinging a severesevere range BP? Fetal responses to sudden hypotension are documented but occur more commonly in mothers receiving epidural anesthesia. In the recent (2013) CMQCC California Preeclampsia Collaborative, among mothers being treated for acute-onset severe hypertension, <1% were associated with significant changes in the fetal heart rate pattern in the hour after treatment (and may have been related to other factors such as the preeclampsia) Severe Hypertension is an emergency and the mother needs emergent treatment.

Are manual BP measurements required/ recommended with blood pressures ≥140/90 or ≥160/110? The most important factor is being consistent: same position, same arm, and right sized cuff.

What about BP measurements that vacillate between severesevere and nearly severe? This is a case of parsing the words versus understanding the reasoning behind the guideline. Women with acute-onset severe hypertension can have strokes. Serial measurements of: 162/105; 158/104; 165/100; 159/109 shows persistence and risk and we recommend treatment.

What about a severe range BP followed in 15minutes by less concerning BP (145/95)? This scenario does not require treatment BUT does indicate the need for frequent monitoring of BP.

What if in another hourhour,, the BP rises again to severesevere range? Here there may be choices: begin treatment or await another BP measurement to document persistent severe range (while preparing the medication). This judgment depends, among other factors, on how low the blood pressures were between the two severe range measurements.

What if the nurse does not take a confirmatory BP for 3030----4040 minutes and it is still severe? Even if the second BP is not taken “within 15 minutes” and it remains in the severe range it is persistent, so treatment should commence immediately. A key educational point is that one severe range BP requires the initiation of frequent BP measurements.

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HYPDRALAZINEHYPDRALAZINE:: OB HHHypertensiveHypertensive EEEmergencyEmergency MMManagementManagement PPPathwayPathway

“Magnesium sulfate is not recommended as an antihypertensive agent, but magnesium sulfate remains the drug of choice for seizure prophylaxis for women with acute-onset severe hypertension during pregnancy and the postpartum period. Starting magnesium should not be delayed in the setting of acute severe hypertension; it is recommended regardless of whether the patient has gestational hypertension with severe features, preeclampsia with severe features, or eclampsia.”6

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LABETALOLLABETALOL:: OB HHHypertensiveHypertensive EEEmergencyEmergency MMManagementManagement PPPathwayPathway

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NIFEDIPINE: OB HHHypertensiveHypertensive EEEmergencyEmergency MMManagementManagement PPPathwayPathway

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EMERGENCY ROOM DEPARTMENT EVALUATION and TREATMENT (Part 1/2)

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EMERGENCY ROOM DEPARTMENT EVALUATION and TREATMENT (Part 2/2)

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EEECLAMPSIAECLAMPSIA ALGORITHM

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PPPATIENTPATIENT EDUCATIONAL RESOURCES Organization Online only Online Handouts Handouts Website Posters Videos (cost) (cost) (free) info

Preeclampsia www.preecl X X X Foundation ampsia.org

https://awh onn.org/ed ucation/hos pital- products/p AWHONN X X X ost-birth- warning- signs- education- program/

https://www .marchofdi March of mes.org/co X X Dimes mplications /preeclamp sia.aspx

Blue Band www.centra care.com/bl X Initiative uebands

https://0j.b5 z.net/i/u/10 ACOG 186768/f/a X cog_faqs.p df

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SAMPLE #1: Patient Education Handout (page 1/1)

High Blood Pressure and Preeclampsia During and After Pregnancy

You have been diagnosed with a condition called "preeclampsia". This condition occurs in pregnancy, but effects may persist after delivery. If you have symptoms such as blurry vision, increasing shortness of breath, abdominal pain or headache that does not resolve, these may be due to preeclampsia. Please contact your provider if you have these symptoms.

Women with preeclampsia are at increased risk of heart disease later in life. We recommend a heart healthy lifestyle including regular exercise (at least 150 minutes of moderate intensity exercise per week), a healthy diet, and regular visits with a primary care doctor. For more information visit: https://www.cdc.gov/physicalactivity .

Blood pressure: A blood pressure cuff has been prescribed for you. Please check your blood pressure every 4 hours for the next 3 days. Tips for taking your blood pressure:  Take your blood pressure on your right arm in a seated position with your arm at rest on your lap.  No smoking within 20 minutes of taking your blood pressure.  Take your blood pressure after you have been seated for at least 10 minutes.

The top number should be more than 80 and less than 150 and the bottom number more than 50 and less than 100.  If the top number is more than 160 and/or the bottom number is more than 110, remain at rest and repeat the blood pressure in 15 minutes.  If the top number remains more than 160 and/or the bottom number more than 110 after a second check, please go to your nearest emergency room

Symptoms of preeclampsia: Please call your doctor or seek care immediately if you have any of the following symptoms,  Headache that does not improve with rest, Tylenol, or re-hydrating  Persistently blurry vision  Chest pain, especially if it does not stop with rest  Worsening shortness of breath

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SAMPLE #2: Patient Education Handout (page 1/1)

What is severe hypertensiohypertension?n?n?n? Severe hypertension is a serious disease related to high blood pressure. It can happen to any woman who has just had a baby up to 6 weeks after thethe baby is born.

Risks to YouYou:: Seizures Organ damage Stroke Death

MEDICAL ALERTALERT---- THIS ZONE IS AN EMERGENCY RED Red zone means go to the nearest Emergency Department or call 911.

 Blood pressure at or exceeding 160/110  Shortness of breath, chest pain or trouble breathing  Constant belly pain or pain just under your ribs  Seeing spots, flashing lights, light sensitivity or blurred vision  Constant headache

CAUTION ––– THIS ZONE IS A WARNING YELLOW Call your provider if you have and of the following signs or symptoms. If you can’t reach your healthcare provider, call 911 or go to an Emergency Department and report that you have recently been pregnant.  Blood pressure at or exceeding 140/90  Unexplained belly pain  Feeling nauseous or throwing up  Swelling in your hands and face  Unexplained headache that won’t go away with tylenol

ALL CLEAR ––– THIS ZONE IS YOUR GOAL GREEN Green zone means continue taking your medications as ordered

 Eating healthy, drinking plenty of water and feel like you are healing well  Feeling confident about caring for yourself and your baby What can you do?  If you had high blood pressure in your pregnancy, ask if you should follow-up with your provider within one week of discharge.  Keep all follow-up appointments.  Watch for warning signs. If you notice any, call your provider. (If you can’t reach your provider call 911 or go directly to and emergency department and report you have been pregnant.)  Trust your instincts

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SAMPLE ###3#333:: PaPatienttient Education Handout (page 1/2)

High Blood Pressure and Preeclampsia During and After Pregnancy

What is high blood pressure? Blood pressure is the pressure of the blood against the blood vessel walls each time the heart contracts (squeezes) to pump the blood through your body. High blood pressure is also called hypertension .

What is preeclampsia? Preeclampsia is a serious disorder that develops during pregnancy or up to 6 weeks after delivery. It can affect many organs (brain, kidneys, and/or liver) in your body. Preeclampsia usually happens in the last half of pregnancy. Preeclampsia can cause:  High Blood Pressure  Protein in the urine  Organ Damage  Seizure  Stroke  Death

What are the symptoms of preeclampsia? Some women may have many symptoms of preeclampsia while others may only have one or two.  Swelling of face or hands  Trouble breathing or feeling short of breath  A headache that is severe or will not go away  Heartburn that will not go away  Seeing spots or changes in vision  Decreased urination or none  Pain in the upper right area of your belly  High blood pressure  Nausea or throwing up  Chest pain  Sudden or rapid weight gain  Confusion

When does preeclampsia occur? Preeclampsia can occur anytime during pregnancy, but most often after 20 weeks. It also can occur in the six weeks after your pregnancy.

What are the risk factors for preeclampsia?  First pregnancy  Carrying more than one baby  A history of preeclampsia in a previous  Certain medical conditions such as diabetes, pregnancy bleeding disorders, or certain auto-immune  Family history of preeclampsia conditions  History of high blood pressure  BMI over 35  History of kidney disease  Fertility treatment  Age 35 years or older

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Hypertension in Pregnancy Care Process Model

SAMPLE ###3#333:: Patient Education Handout (page 2/2)

What are the risks for my baby if preeclampsia occurs?  Premature delivery  Stillbirth

What are the long-term risks for me if preeclampsia occurs?  Preeclampsia can cause serious health problems for you and could have lifelong impacts.  Women who have had preeclampsia have increased risk of: o Heart disease, heart attack, and stroke o High blood pressure

If you have had preeclampsia once, it increases your risk of preeclampsia with future pregnancies.

What should you do if you have been diagnosed with preeclampsia or postpartum preeclampsia?  Keep your follow-up appointments with your healthcare provider, even if you are feeling well.  Expect your first follow-up appointment after delivery to be within 2-5 days of discharge from the hospital.  Continue your prescribed medications as directed.

Your provider will be following your health closely during your pregnancy and for 6 weeks after your baby is born.

If you notice any of the symptoms of preeclampsia listed above, seek medical attention. Get a ride to your closest emergency room or call 911 and report the symptoms you have been experiencing.

* It is important to let healthcare providers know if you are pregnant or have recently been pregnant.

If you have been given a blue wrist band to wear, the band is to alert healthcare workers and others of your condition. Wear this band during your pregnancy and continue to wear it after you deliver. Leave the blue wristband on until your healthcare provider takes it off or tells you to take it off.

Many complications of preeclampsia can be prevented. Your healthcare provider is working to raise awareness of preeclampsia in our communities by using the blue medical alert bands and education.

Consumer Resources for Blood Pressure

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Monitoring at Home:

How to Pick a Home Blood Pressure Monitor from Web MD: https://www.webmd.com/hypertension-high-blood-pressure/how-pick-home-blood-pressure- monitor#1

The 6 Best Blood Pressure Monitors of 2020; Get accurateaccurate measurements at home and onon----thethethethe----gogo with these devices : https://www.verywellhealth.com/best-blood-pressure-monitors-4158050 Best Overall: Omron Upper Arm Blood Pressure Monitor at Amazon Best Budget: Greater Goods Blood Pressure Monitor Cuff Kit at Amazon Best forforfor Large Arms: LifeSource Upper Arm Blood Pressure Monitor at Amazon

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Minnesota Perinatal Quality Collaborative

Hypertension in Pregnancy Care Process Model

The Blue Band Project https://minnesotaperinatal.org/hypertension_in_pregnancy

One Organization to get your own customized and branded bands:

andi @imagebuild.com

◦ Phone# 320-281-2325 ◦ 800-324-8190

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Minnesota Perinatal Quality Collaborative Hypertension in Pregnancy Care Process Model

How to implement the Blue Band Initiative at your facility:

1. Design and purchase your own blue bands a. Distribute to: i. Hospitals ii. Clinics 2. Create patient education 3. Create your own patient education online resource or link to MNPQC’s page a. Link to other resources 4. Education: a. All Clinical staff i. Standardized approach to BP measurement ii. Standardized approach to hypertensive treatment in peripartum women iii. Multidisciplinary Simulation of emergency treatment in all healthcare entry points 5. Communicate to: a. Clinical staff (Nurses etc.) b. Providers i. OB providers ii. Family Practice iii. Emergency Services iv. Internal Medicine v. Hospitalists vi. Laborists vii. Clinic Personnel c. Media i. Local news papers ii. Local news media iii. Your social media sites (i.e. Facebook, Twitter, Instagram etc.) d. Your own facility website e. Emergency Medical services i. Ambulance/first responders f. Police g. Fire Department h. Sheriff’s offices

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MinnesotaMinnesota PerinatalPerinatal Quality Quality CollaborativeCollaborative HypertensionHypertension inin PregnancyPregnancy CareCare ProcessProcess ModelModel

References: ACOG taskforce on hypertension in pregnancy. Hypertension in pregnancy. Obstet Gynecol. 2013 Nov;122(5):1122-31

ACOG Practice Bulletin No. 202. Gestational hypertension and preeclampsia. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e1-25.

ACOG Practice Bulletin No. 203. Chronic hypertension in pregnancy. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e26–50.

ACOG committee opinion no. 560: Medically indicated late- preterm and early-term deliveries. American College of Obstetricians and Gynecologists. (2013). Obstetrics and gynecology, 121(4), 908.

ACOG Committee Opinion No. 764. Medically indicated late-preterm and early-term deliveries. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e151–55.

ACOG Committee Opinion No. 767. Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133.

AHA Statement: https://www.ahajournals.org/doi/full/10.1161/01.HYP.0000150859.47929.8e

Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol. Jul 2008;199(1):36 e31- 35; discussion 91-32 e3711.

CMQCC. Druzin, M.L, Shields, L.E., Peterson, N.L., Valerie Cape, V. (2013). Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, November 2013.

Eggleston N, Trojano N, Harvey C, Chez B. Clinical care guidelines. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2013.

Mann, S., Hollier, L.M. , McKay, K., Brown, H. (2018). What we can do about maternal mortality – and how to do it quickly. NEJM 2018 Nov 1;379(18):1689-91

Myers MG. The great myth of office blood pressure measurement. J Hypertens. 2012;30(10):1894-1898.

Myers MG, Godwin M, Dawes M, et al. Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: randomised parallel design controlled trial. BMJ. 2011;342(Feb 7):d286.

Nietert PJ, Wessell AM, Feifer C, Ornstein SM. Effect of terminal digit preference on blood pressure measurement and treatment in primary care. Am J Hypertens. 2006;19(2):147-152

O’Brien E. Has conventional sphygmomanometry ended with the banning of mercury? Blood Press Monit. 2002;7(1):37-40.

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O’Brien E, European Society of Hypertension Working Group on Blood Pressure M. The Working Group on blood pressure monitoring of the European Society of Hypertension. Blood Press Monit. 2003;8(1):17-18.

Perry I, Beevers D. The definition of preeclampsia. Br J Obstet Gynaecol. 1994;101(7).

Pickering T, Hall J, Appel L, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public education of the American Heart Association Council on high blood pressure research. Hypertension. 2005;45:142.

Pilgram, J., Schub, E., & Pravikoff, D. Blood Pressure Reading, Indirect: Taking in an Adult Patient. CINAHL Nursing Guide, 2018.

Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol. Jul 2003;102(1):181-192.

Staessen JA, Li Y, Hara A, Asayama K, Dolan E, O’Brien E. Blood pressure measurement Anno 2016. Am J Hypertens. 2017;30(5):453- 463

The Joint Commission. Preventing Maternal Death. Sentinel Event Alert. Issue 44. 2010; http://www.jointcommission.org/sentinal_event_alert_issue_44_preventing_maternal_death. Accessed January 26, 2010.

Turner J. Diagnosis and management of pre-eclampsia: an update. International Journal of Women’s Health. 2010; 2:327-337.

Waguespack, D. R., & Dwyer, J. P. (2019). Assessment of Blood Pressure: Techniques and Implications From Clinical Trials. Advances In Chronic Kidney Disease, 26(2), 87–91. https://doi.org/10.1053/j.ackd.2019.02.002

Yancey L, Withers E, Bakes K, Abbot J. Postpartum preeclampsia: emergency department presentation and management. J Emerg Med. 2011;40(4):380-384.

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Minnesota Perinatal Quality Collaborative Hypertension in Pregnancy Care Process Model

MNPQC Hypertension Committee Members who worked on this documentdocument::::

Todd Stanhope, MD OB/Gyn

Becky Gams, MS, APRN, CNP Advanced Practice Nurse Leader, MHealth Fairview AWHONN MN Section Website Coordinator

Melissa Bray-Erickson, MSN Ed., BSN, RNC-MNN, PHN Nurse Clinician, St. Cloud Hospital AWHONN MN Section Chair

The Entire MNPQC Hypertension Team:

Abby Skoyen Julie Shelton Alina Kraynak Kathy Pfleghaar Angela Thompson Katie Linde Anne Walaszek Marijo Aguilera Becky Gams Melanie Dixon Bonnie Hansen Melissa Erickson Cameron Berg Michael Kassing Carrie Neerland Phillip Rauk Charles Snow Sara Wiggins Elizabeth Baldwin Shalana Bolton Elizabeth Elfstrand Summer Johnson Heather Brusegard Susan Boehm Jaime Slaughter-Acey Todd Stanhope Janyne Althaus Tony Pelzel

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