Severe Maternal Morbidity & Obstetric Safety Bundles Autumn Broady, MD, MPH Fellow, Maternal Fetal Medicine University of Hawaii John A. Burns School of Medicine Dept. of Obstetrics, Gynecology & Women’s Health Child Death Review-Maternal Mortality Review Programs Summit June 15th, 2016
Maternal Mortality: Tip of the Iceberg
Acute Renal Failure
100x More Common
Cardiac Events Hemorrhage
Callaghan et al. Obstet Gyn. 2014.
Shock Respiratory Distress Syndrome Thromboembolism
Defining Severe maternal morbidity
NO Standard Definition: Maternal morbidity Acute maternal morbidity Severe maternal morbidity Severe acute maternal morbidity Severe obstetric complications, absolute maternal indications Maternal “near-miss” Often involving organ system failure
Callaghan et al. Obstet Gynecol. 2014. Koblinsky et al. J Health Popul Nutr. 2012.
Redefining Severe Maternal Morbidity
ICU admission during pregnancy Transfusion of ≥ 4 units of blood products
Callaghan et al. Obstet Gynecol. 2014.
The Iceberg: Severe Maternal Morbidity
Obstet Gynecol. 2012;120:1029-1036.
The Iceberg: Severe Maternal Morbidity
All delivery & postpartum hospitalizations 1998-2009 25 severe morbidities 49 million delivery hospitalizations 738,124 postpartum hospitalizations 597,920 with severe maternal morbidity
493,397 during delivery 104,532 postpartum
Obstet Gynecol. 2012;120:1029-1036.
The Iceberg: Severe Maternal Morbidity
AFE Anesthesia complications Aneurysm ARDS/Resp. failure Cardiac Arrest/V. fib CHF Cardiac surgery DIC Eclampsia ICH Internal abdominal/thorax injuries
Obstet Gynecol. 2012;120:1029-1036.
Renal Failure Sickle cell crisis Stroke Sepsis Transfusion VTE/PE
The Iceberg: Severe Maternal Morbidity
Significant increases compared to 1998-1999
Acute renal failure (97%) Shock (100%) Thrombotic PEs (72%) Respiratory distress syndrome (75%) Acute MI (79%) Blood transfusions (183%) Aneurysms (195%) Operations on heart & pericardium (75%)
Obstet Gynecol. 2012;120:1029-1036.
The Iceberg: Severe Maternal Morbidity
Severe complications
Delivery increased by 75% Postpartum increased by 114%
Decreases in delivery hospitalization morbidities of severe anesthesia complications, pulmonary edema & eclampsia
No significant decreases for any category of severe complications in postpartum hospitalizations
13 indicators of severe morbidity at least doubled
Obstet Gynecol. 2012;120:1029-1036.
The Iceberg: Severe Maternal Morbidity
Annually, with ~4 million births, 129 episodes of severe maternal morbidity per 10,000 births approximately 52,000 women
Callaghan et al. Obstet Gynecol. 2012;120:1029-1036. King. Semin Perinatol. 2012.
The good news… What can we do about it????
AJOG. 2016 Apr;214(4):444-51
Evidence-based Facilitate measureable improvements in quality of care Aid in diagnosis prevents/limits morbidities Customizable Limit human errors & augment memory
safehealthcareforeverywoman.org
cmqcc.org
Reducing Maternal M&M: Obstetric Hemorrhage Protocols
“Code Crimson” Admission risk assessment Unit-standard EBL & vital sign-driven stages Hemorrhage cart Immediate access to hemorrhage medications Response Team Blood bank partnership Universal active management of 3rd labor stage Semi-quantitative techniques to assess EBL Debriefing culture
Obstetric Hemorrhage Toolkits
Significant differences
Resolution of hemorrhage at an earlier stage less interventions Decreased amount of blood products transfused & monthly utilization 64% reduction in DIC Improvements in staff & physician perceptions of team communication & confidence in handing PPH Improvements in staff & physician perceptions of patient safety
Shields et al. AJOG. 2011. 205;368.e1-8.
Reducing Maternal M&M: Hypertension Mgmt Critical initial step is administration of anti-hypertensives with persistent blood pressures ≥ 160 systolic and/or 105 diastolic within 1 hour Martin et al, stroke occurred in:
23/24 (95.8%) women with systolic BP > 160mm Hg 24/24 (100%) had a BP ≥ 155 mm Hg 3/24 (12.5%) women with diastolic BP > 110mm Hg 5/28 (20.8%) women with diastolic BP > 105mm Hg Martin et al., Obstet Gynecol 2005;105-246.
Reducing Maternal M&M: Hypertension Mgmt
Expeditious administration of antihypertensives Magnesium sulfate therapy for seizure prophylaxis & for eclampsia Algorithms for acute treatment of severe hypertension & eclampsia should be readily available & posted in L&D Early post-discharge follow up for BP check Postpartum patients presenting to ED with sx of PE should be assessed or admitted by obstetrical service. If treated in ED, adequate OB follow up must be arranged All institutions should consider preparing severe PE/eclampsia toolbox
Reducing Maternal M&M: VTE
Maternal mortality: 6.24 -> 4.67 per 100,000
Lewis. Semin Perinatol. 2012. RCOG. 2009.
Reducing Maternal M&M: VTE Prophylaxis
https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/VTESlideSetNov2015.pdf?la=en
OR GOOGLE “ACOG” and “VTE”
Tertiary care center = almost everyone!!!
VTE Prophylaxis
Information on
Timing of neuraxial anesthesia Thrombophilias Contraindications to chemoprophylaxis HIT Post-cesarean chemoprophylaxis Therapeutic dosing
Conclusions
Maternal morbidity and mortality are increasing Maternal morbidity and mortality are preventable in most cases The use of safety bundles, availability of algorithms, and implementation of toolkits can improve awareness, facilitate proper diagnosis, and ensure standard-of-care treatment for women with pregnancy-associated complications The healthcare community must work together to improve maternal health in Hawaii
Mahalo!
Special thanks to Dr. Iwaishi
Questions?
[email protected]
References
Callaghan WM, Grobman WA, Kilpatric SJ, Main EK, D’Alton M. Facility-based identification of women with severe maternal morbidity: its time to start. Obstet Gynecol. 2014 May;123(5):978-81. doi: 10.1097/AOG.0000000000000218.
Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012 Nov;120(5):1029-36. doi: http://10.1097/AOG.0b013e31826d60c5.
King JC. Maternal mortality in the United States- Why is it important and what are we doing about it? Semin Perinatol. 2012; 36: 14-18.
Hankins GDV, Clark SL, Pacheco LD, O’Keefe D, D;’Alton M, Saade GR. Maternal mortality, near misses and severe morbidity: lowering rates through designated levels of maternity care. Obstet Gynecol. 2012; 120: 929-34.
Arora KS, Shields LE, Grobman WA, D’Alton ME, Lappen JR, Mercer BM. Triggers, bundles, protocols and checklists—what every maternal care provider needs to know. Am J Obstet Gynecol. 2016 Apr;214(4):444-51. doi: 10.1016/j.ajog.2015.10.011. Epub 2015 Oct 23.
Shields LE, Smalarz K, Reffigee L, Mugg S, Burdumy TJ, Propst M. Comprehensive maternal hemorrhage protocols iimprove patient safety and reduce utilization of blood products. Am J Obstet Gynecol. 2011 Oct;205(4):368.e1-8. doi: 10.1016/j.ajog.2011.06.084. Epub 2011 Jun 29.
Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol. 2015 Mar;212(3):272-80. doi: 10.1016/j.ajog.2014.07.012. Epub 2014 Jul 12.
Einerson BD, Miller ES, Grobman WA. Does a postpartum hemorrhage patient safety program result in sustained changes in management and outcomes? Am J Obstet Gynecol. 2015 Feb;212(2):140-4.e1. doi: 10.1016/j.ajog.2014.07.004. Epub 2014 Jul 11.
Martin JN Jr, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe pre-eclampsia: a paradigm shift focusing on systolic blood pressures. Obstet Gynecol. 2005 Feb;105(2):246-54.
Lewis G. Saving mothers’ lives: the continuing benefits for maternal health from the UK confidential enquiries into maternal deaths. Semin Perinatol. 2012; 36: 19-26.
Touqmatchi D, Cotzias C, Girling J. Venous thrombophrophylaxis in pregnancy: the implication of changing to the 2010 RCOG guidelines. J Obstet Gynaecol. 2012 Nov;32(8):743-6. doi: 10.3109/01443615.2012.711387.
RCOG Greentop Guidelins 37a: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf
Why the increase??
ICD 9 -> 10 switch in 1999
New US standard death certificate introduced 2003 with pregnancy checkbox 35 states as of 2012 Expanded to 48 states as of 2013
Advancing maternal age
Obesity -> HTN, DM, other preventable chronic disease
Rising cesarean section rate
Unmasking of underlying medical conditions
