Putting the “M” Back into Maternal-Fetal Medicine

Q&A on improving maternal care and reducing maternal mortality

Article

In response to the United States’ relatively high maternal mortality and morbidity rates as well as its socioeconomic and racial disparities, the Society for Maternal Fetal Medicine has developed an initiative designed to focus on maternal healthcare in recent years. Here, Brenna Hughes, MD, MSc, ob-gyn and chair of Duke OBGYN’s new Quality, Safety and Peer Review Committee, discusses her work to develop and study quality improvement efforts to address mortality and mobidity rates.

 

Tell us about your research on interventions for improving maternal outcomes.

The American College of Obstetricians and Gynecologists (ACOG) has a committee opinion with treatment algorithms and recommendations (see sidebar) for caring for patients with severe hypertension in pregnancy—one of the most significant causes of maternal mortality. In response, one of my fellows when I was at Brown pulled together a multidisciplinary task force to review the committee opinion, revise institutional policies for gestational hypertension and preeclampsia, and update electronic order sets. She also made badge buddies and reminders for the physician work rooms and similar locations  to make it easy for people to do the right thing.

We then assessed outcomes, with a primary outcome of reaching goal blood pressure (systolic 150 mm Hg and diastolic 100 mm Hg or less) within one hour of the initial intervention—ACOG’s recommended target. Although this goal was not met, we did see decreased time to achieve goal blood pressure after the intervention. That’s significant because, for any individual woman, that decreased time could be the difference between having a stroke or not. So, while we were disappointed that the intervention wasn’t as effective as we had hoped, we were encouraged that it did lead to improved care.

Now that you are at Duke, how are you building on your research to address the high incidence of maternal mortality and morbidity?

One of the goals of the Quality, Safety and Peer Review Committee is to ensure we’re optimizing this ACOG committee opinion. Duke has already implemented a similar approach at Duke to the study I did at Brown, including an electronic order set for the management of severe hypertension. Our plan is to start auditing its use and seeing how well we’re using the order set and controlling hypertension. And even though we have not measured outcomes yet, our acuity at Duke is quite high, and our nurses are very comfortable working with patients with high-risk pregnancies. So, I anticipate that our highly trained unit will quickly be able to demonstrate improved care.

2017 ACOG 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.

From: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Committee Opinion No. 692. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e90–5.

What are important components of an effective quality improvement effort?

It’s critical to keep in mind that quality improvement is a continuous process. First, you start an initiative, and second, you continuously monitor your quality as quality measures get implemented. You need to be constantly thinking about how to optimize the initiative and what the potential barriers are. Then you need to make iterative changes to make sure you continue to move quality forward.