By Kathleen Berkowtiz, MD
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A recent report from the Centers for Disease Control and Prevention calculated a national pregnancy-related mortality ratio (PRMR) of 17.2 per 100,000 births, with a great deal of variation based on socioeconomic status. Maternal mortality review committees found that three in five of these deaths were preventable.
This report calls attention to the stark reality of maternal mortality in the United States, which, according to Beri Ridgeway, MD, Chair of Cleveland Clinic’s Ob/Gyn & Women’s Health Institute, is predictive of societal health. At Cleveland Clinic, we are committed to moving the needle on preventable maternal morbidity and mortality. Among our efforts is the development and implementation of order sets and protocols to optimize the management of the three causes of obstetric emergencies: obstetric hemorrhage, preeclampsia and hypertensive disorders, and deep vein thrombosis (DVT).
Obstetric hemorrhage occurs in 7% – 10% of our births. With approximately 5,500 deliveries per year at Cleveland Clinic Fairview Hospital—where I practice—obstetric hemorrhage is a near daily occurrence. In order to ensure each patient is screened, bleeding risk is assessed for every patient; patients are categorized as green (i.e., low risk for hemorrhage), yellow (moderate risk), or red (high risk) in the electronic health record (EHR). We attempt to correct prenatal anemia before delivery.
We have both order sets and protocols in place to identify the amount delivery-related blood loss, along with a set of graduated responsive steps using the ACOG definitions of hemorrhage stage. We also hold drills on how to respond to hemorrhage in various situations. Everyone who will be touching a patient participates in these drills: anesthesiologists, midwives, physician assistants, physicians and residents. Each delivery ward has a hemorrhage cart that contains checklists, instructions and supplies for responding to hemorrhage. If you are going to be involved in care of anyone on either the antepartum labor and delivery or postpartum floors, you will at some time be involved in the drills on obstetric hemorrhage.
We track patient outcomes and quality measures to ensure compliance with our protocols, and for purposes of continuous improvement. We are working to formalize quantitative measures of blood loss. Any stage three blood loss is quickly reviewed by our multidisciplinary Quality Improvement Committee.
Looking at all phases of preeclamptic disease in the third trimester of pregnancy, 13% – 15% of patients will have one of the following five diagnoses: gestational hypertension, preeclampsia without severe features, preeclampsia with severe features; Hemolysis, Elevated Liver enzymes, Low Platelet count (HELLP) syndrome or eclampsia. Antihypertensive treatment—generally intravenous hydralazine or labetalol and oral nifedipine—should be initiated as soon as possible for acute-onset severe hypertension (systolic blood pressure of 160 mm HG or more, or diastolic blood pressure of 110 mm HG or more, or both) that persists for 15 minutes or more. In a hypertensive emergency, the treatment goal is not normalization of blood pressure, but rather, achieving a range of 140 – 160/90 – 100 mmHG in order to prevent repeated, prolonged exposure to severe systolic hypertension, with subsequent loss of cerebral vasculature autoregulation. Stabilization should occur prior to delivery.
As with the care plans for obstetric hemorrhage, blood pressure thresholds along with other maternal early obstetric warning signs (MEOWS) are built into every order set. If a patient reaches the threshold for high blood pressure, a de-escalation order set, which includes medication administration in 60 minutes or less, is automatically triggered. This is a new initiative for 2019, with mandatory training for caregivers anywhere antepartum or postpartum patients might seek healthcare (including both community office settings and the Emergency Department). Women who develop any of the five hypertensive disorders receive an extra postpartum visit within one week of hospital discharge. This allows us to identify and treat blood pressure that remains uncontrolled.
Patients play a role in monitoring their symptoms as well. About half of our patients who are admitted for postpartum preeclampsia seek medical care in response to their own symptoms, which we discuss as part of our discharge procedures and include in their discharge paperwork. When patients are concerned about recurrent headache, nausea or vomiting, or right upper quadrant pain, some seek emergent medical care rather than waiting for their one-week hypertension check. We find that some of these patients come in as early as 3 – 4 days following discharge.
We are working with our EHR platform to develop a means of tracking the speed of our response to acute hypertensive events, and our goal is to be able to measure this by the end of 2019. In addition, we are currently gathering our data on our postpartum admission rates. We hope to identify opportunities for decreasing the risk of postpartum hypertensive events. Even in California, where the California Maternal Quality Care Collaborative (CMQCC) has publicized best practices for several years now, only about 60% of hypertensive events are appropriately treated within 60 minutes.
Deep vein thrombosis
Approximately 70% – 80% of the deep vein thrombosis events are preventable. Risk of venous thromboembolism (VTE) is increased five times higher during pregnancy, and astonishingly 60 times higher during the first six weeks postpartum. Thorough risk assessment for VTE should occur at four critical time points: at the first prenatal visit, during any antepartum hospitalizations, postpartum and after discharge. Major risk factors for pregnancy-related VTE include previous VTE, reduced mobility, thrombophilia, acute infection, chronic medical conditions and obesity. Depending on individual patient risk factors, thromboprophylaxis with unfractionated heparin or low-molecular weight heparin may be warranted. Our DVT protocol ensures that all of our patients are treated with either mechanical or chemical prophylaxis. Those at highest risk, such as our postop patients with higher BMIs, are treated with prophylactic doses of enoxaparin, for instance, in order to decrease the risk of DVT. Care must be taken in the selection of thromboprophylactic agents in patients who are antepartum and may be facing delivery and risk of a bleeding event. We have protocols in place for that as well.
To ensure compliance with these DVT-related protocols, we measure a variety of outcomes, including the appropriate use of chemical prophylaxis. We are currently improving our postpartum discharge summaries to educate patients about the signs and symptoms of DVT.
As a healthcare system, we are doing everything possible to develop solutions to maternal morbidity and mortality. Once Cleveland Clinic has successfully scaled these initiatives, we intend to partner with the greater Cleveland community, and hope to serve as a model for other Cuyahoga county-area hospitals. We want to do more than just prevent maternal deaths locally; we want to see them decrease throughout the state of Ohio.