A poll of the audience found that 31% have a comprehensive, standardized protocol for severe pregnancy hypertension in their hospital, 22% have one that could be improved, 35% don’t have one, and 11% had not a clue.(The percentages added up to 99% rather than 100% when the survey results were displayed at the meeting.)
• Thromboembolism: The keys to preventing venous thromboembolism are to have protocols for use of a sequential compression device, pharmacologic prophylaxis for higher-risk mothers, and antenatal prophylaxis, Dr. Main said.
A draft safety bundle for prevention of venous thromboembolism during cesarean section calls for applying a sequential compression device prior to delivery. Add chemoprophylaxis to all who already are receiving prophylaxis or full anticoagulation, patients with a history of thromboembolism who are not already on chemoprophylaxis, mothers with a family history of venous thromboembolism and any thrombophilia, mothers who are morbidly obese, or any patients with a score of two or more for other, more minor risk factors.
Obesity is "the big risk factor in California," he said. Two-thirds of pregnant Californians who die from thomboembolism have a body mass index greater then 40 kg/m2.
An unexpectedly high proportion of the audience – 29% said that their hospital has a standardized protocol for using Lovenox (enoxaparin) for obstetric patients at higher risk for venous thromboembolism. Few local hospitals will have such protocols, Dr. Main noted, and if they have them, they’re usually very complicated. Another 18% at the meeting said they have such a protocol but it could be improved; 38% said they don’t have a protocol, and 15% had no clue.
• Warnings: Draft criteria for an Early Warning Tool that should trigger an evaluation of maternal safety include specific vital signs and important symptoms. Troubling vital signs include a systolic blood pressure below 90 mm Hg or above 160 mm Hg; diastolic blood pressure higher than 100 mm Hg; sustained heart rate below 50 or above 120 beats per minute; respiratory rate slower than 10 or faster than 30 breaths/minute; oxygen saturation less than 95% room air (at sea level); or oliguria less than 30 mL/hour for 2 hours.
Among symptoms, maternal agitation, confusion or unresponsiveness often is a sign of low oxygen saturation, Dr. Main said. A patient with hypertension who reports an unremitting headache is a red flag. Shortness of breath in a patient with preeclampsia or hypertension should raise big concerns about the development of pulmonary edema and cardiovascular problems.
As a core safety principal, however, the bedside clinician should always feel comfortable escalating concern at any point, because these criteria can’t address all scenarios, he added. These warning criteria are being rolled out in New York State hospitals for a trial, he said.
• Cardiovascular: There are not enough data yet to identify opportunities for safety improvements related to cardiovascular or cardiomyopathy risks in pregnancy, so instead of a safety bundle Dr. Main presented three clinical pearls from California’s work on maternal safety.
Morbid obesity plus hypertension equals high risk for cardiomyopathy, especially if the patient is African American and older than 35 years, he said. There are not many pregnant women with known underlying cardiovascular disease, but this group should be followed closely by a multidisciplinary team, perhaps in a tertiary care center. The third pearl was new to Dr. Main: the onset of wheezing in the third trimester, which is not likely to be asthma but cardiac in origin and deserves a patient referral for evaluation.
Dr. Main reported having no financial disclosures.
On Twitter @sherryboschert