Transcription:
How Can Hospitals and Physicians Better Diagnose and Treat Preeclampsia

Prakash Chandran (Host):  Left untreated, preeclampsia can lead to serious, even fatal complications for pregnant women and their babies. In this episode, we explore how hospitals and physicians can better diagnose, treat and manage preeclampsia. Let’s talk with Dr. Mark Simon, the Chief Medical Officer for OB Hospitalist Group and Eleni Tsigas, the CEO of the Preeclampsia Foundation. This is the Obstetrics Podcast from OB Hospitalist Group. I’m Prakash Chandran. So, first of all, Dr. Simon, we’ll start with you. What exactly is preeclampsia and why is it such a serious pregnancy complication?

Mark Simon, MD, MMM, CPE (Guest):  Yeah, so preeclampsia is a condition in pregnancy where you have – where the patient has a rising blood pressures, typically, so hypertension or elevated blood pressures. It can be associated with other organ damage. So, you can have liver problems associated with it. You can have neurological problems associated with it. It can lead to strokes and left untreated, it could lead to seizures which is called eclampsia and it can ultimately lead to death in the most severe cases.

Host:  And just to expand on that a little bit more. Do preeclampsia concerns end after delivery?

Dr. Simon:  No. Patients can actually develop preeclampsia or complications from preeclampsia after delivery in the weeks following a pregnancy. So, it is important that everyone is acutely aware of that even when the patient goes home from the hospital.

Eleni Tsigas (Guest):  And I have something to add to that. One of the most common phrases that we sometimes hear uttered is that delivery is a cure for preeclampsia. We are really working hard to sort of strike that language from hospital and clinical messaging because it really sends a message that the problem has been resolved and everybody sort of lightens up their surveillance and mom goes home and assumes that anything else going on is not related to the pregnancy. And so, it’s dangerous in terms of not sending her home with warning signs that she should still be alert to and then it also can send a false message to the hospital staff that gee mom’s had the baby, yes she had preeclampsia but we don’t need to pay as much attention now and really the data shows that some of the worst outcomes happen in the postpartum period.

Host:  So, Eleni, I want to stick with you on this one and talk about prevention. Is it possible for preeclampsia to actually be prevented?

Eleni:  Well the short answer would be no but it’s a very nuanced answer because when you look at all of the risk factors that put a woman at higher risk for developing preeclampsia; some of those are modifiable, some of them are not. And there’s a lot of debate in the research field as to whether or not any of the interventions would actually prevent preeclampsia. If you are destined to get it, then you are destined to get it. Having said that, there are some things that increasingly are being recognized. One of them being aspirin, that there is for a certain population of women who are at higher risk; that should be taking aspirin as early as the first trimester, at the end of the first trimester and it has been shown to reduce the incidence of preeclampsia.

The key is finding the right women who should be taking it and there’s a lot of debate going on right now about how to screen them and how to identify who should be taking it. The US Preventative Services Task Force and ACOG have aligned around what are considered the high risk women who absolutely should be taking it and those who might have some moderate risk factors and if they have two or more of those; that they should be taking it. When you add all those up, a good number of women probably should be taking aspirin. Dr. Simon might feel differently and of course every physician sort of chooses to embrace the guidance a little differently. But aspirin is certainly one option.

Host: How do indicators for pre-eclampsia tie into prevention?

Dr. Simon: I think the other thing that goes along with prevention though is not strictly prevention as much as being alert so that intervention can happen as quickly as possible. The one thing we don’t want is women being rushed to the hospital for what I call that 11^th hour crash section because everything has gone south really fast. And that’s not often true. I mean yes, preeclampsia can strike very quickly, and it can go from nothing to horrible very quickly. But often there are some leading indicators and we do need to be alert to that clinically and we need to be alert to that in terms of patients and what we’re helping them understand and recognize, the warning signs, as we say so that they are getting themselves to care as quickly as possible.

Host:  So, Dr. Simon, moving to you, how do you actually go about diagnosing preeclampsia at the hospital?

Dr. Simon:  As was stated, preeclampsia can be diagnosed at any point in an individual’s pregnancy. It could be diagnosed in an office setting or in the hospital setting and regardless, the key factor that you look at are a patient’s vital signs, most importantly, the blood pressure and you combine that with a good history so you get symptoms that the patient may be experiencing. You can also get some additional information from a variety of lab tests whether that’s looking at urine tests, or blood tests that can help identify whether some of that end organ damage we talked about earlier is occurring and if you put that all together; with the right history and the right background for the individual, it puts together a picture of someone who has preeclampsia.

Host:  And again, to expand on that a little bit more, what exactly should physicians and hospitals do differently to manage preeclampsia?

Dr. Simon:  One of the biggest things that hospitals and clinicians need to do is just have a keen awareness that a pregnant patient could present with preeclampsia both before delivery and after delivery as we talked about. So, when a patient who is either pregnant or has recently delivered presents with elevated blood pressures; one of your differential diagnoses has to be preeclampsia. And you have to either rule it out or rule it in, right? So, you have to be aware of it.

So, one is keen awareness amongst multiple individuals. That’s nursing staff, that’s the clinicians, the physician or midwife, that could be an ER physician because remember if they are postpartum and had their baby already, they most likely would present to an emergency room where they would be seen by an ER physician or a physician’s assistant in that area. So, all of these individuals have to be keenly aware and then I think it’s also important that everyone on the labor and delivery unit and in that hospital for that matter, is aware of the treatment algorithms, the protocols that exist for managing hypertension in pregnancy and activate those protocols as soon as the diagnosis or the symptoms present so that the patient can be treated appropriately and hopefully doesn’t develop any of the adverse sequalae that can occur with preeclampsia.

Eleni: About 60% of the maternal deaths from preeclampsia were considered preventable. And what we have found is that some of the basic things that need to be happening in the hospital like treating her blood pressure, not letting it rise as high as many people have been letting it rise in the past; has been a core intervention that has to happen and we’re really pushing for that to happen within an hour, ideally even sooner than an hour.

I think historically, people have seen magnesium sulfate which is a very important treatment for preeclampsia to prevent seizures, but people have seen that as the treatment for the hypertension. And it’s not. It’s a treatment to prevent seizures. So, this really strong focus now on antihypertensives and getting them on board as quickly as possible is part of these protocols that Dr. Simon is referring to and is already showing to make a difference. The states that have really aggressively pushed for these like California and Illinois and some others, are seeing a very measurable decline in maternal mortality and morbidity as a result of some of these interventions that happen in that hospital setting.

Host:  Yeah, I know this ties into the maternal levels of care and probably also why OB hospitalists are in a unique position to address preeclampsia wouldn’t you say Dr. Simon?

Dr. Simon:  Yeah, I think that OB hospitalists in particular, are well-suited to help address this crisis that we have with treating hypertension in pregnancy. First off, the hospitalists are physically present 24/7. Secondly, they are usually or should be well-versed in these hypertensive protocols and being keenly aware of those issues. And since they are physically present, the OB hospitalist is able to collaborate in a very timely manner with the nursing staff whether that’s in the emergency room or whether it’s on labor and delivery and they can collaborate very quickly to ensure that these antihypertensive medications are initiated very soon after the diagnosis is made and as Eleni said, you don’t want that to necessarily be an hour. If we can get those medicines started within 30 minutes; that’s even better. And it helps to prevent these negative sequelae that can happen with preeclampsia.

Eleni:  And I would say a resounding yes, yes. I mean I think that that’s one of the strengths that hospitals bring to this is that they are so connected to the protocols and with large hospitals that have physicians with privileges there that are coming from all different private practice and all different settings; they’re potentially bringing a lot of experience and diverse opinions about how these women should be treated and one of the things that we’ve learned over time yes, every woman should be treated very individually, absolutely. But we consider these protocols as sort of the lowest common denominator that absolutely everyone should be doing, and I think hospitalists bring that consistency of care to the setting and it’s super important role for them.

The one thing that’s interesting that I would say and I don’t know if this is an opportunity to sort of advocate for this practice; the one disadvantage hospitalists often have is that they haven’t seen the patient before she’s come through those doors. And one of the things that happens with preeclampsia is that her condition and I mean generally this is recognized as the edema that can happen in her face and upper extremities that is not a diagnostic tool but it is an indicator that something’s going on with this woman and the evolution of her pregnancy and the evolution of how she looks through that pregnancy is something that a hospitalist may not see. And one of the things that we would really strongly advocate for is having a photo in her EMR of what she looked like before either early, early in pregnancy or right before she got pregnant just so that that hospitalist can see this patient in his or her bed and see a picture and go wow, this is a whole different person and not just somebody who is carrying a lot of extra weight normally.

Otherwise, we are very happy with the consistency of care that hospitalists can bring to the equation.

Host:  And just to expand on this hypertension safety bundle a little bit more. I’m curious as to if there are any mental health inter-conception or post-partum factors that the bundle does not address that hospitalists play a role with?

Eleni:  Well if I could take a stab at this. One of the issues is that women are discharged home after what might have been, especially to them, a traumatic birth. And the hospital team may navigate the preeclampsia case very efficiently, very effectively and see the conclusion of that as something that – it was successful. I say like everyone is high fiving each other like wow, we really handled this well. And that may be the case and from a clinical perspective that may be an appropriate sort of debrief. But the fact is that for those of us who have experienced this; it most likely came completely out of the blue, completely different than what we expected of our birth experience and I don’t mean just sort of the detailed birth plan; I mean wow, I’m literally looking at a life threatening situation for me or my baby.

And that can be mentally, emotionally very, very traumatic. And so, one of the things that the hospital team needs to recognize is that very real possibility that mom is going home kind of shell shocked and in severe, severe cases; with PTSD. And it may not even surface until weeks later. And for her partner, it has been shown that dads often have PTSD from these really traumatic situations four to six months later. So, I think prepping her and the family and saying this was really difficult. That transition of care back to her care provider really needs to come with some very deliberate affirmation that she went through a very difficult situation, this was unexpected, it was traumatic and to really set her up for if you are having difficulty processing this; that’s entirely normal. Normal doesn’t mean you shouldn’t do anything about it. Normal means you should do something about it. But don’t feel like you need to suffer in silence. And that’s one of the things that we have found that’s just heartbreaking is that women will suffer in silence because they feel very isolated in what happened. Everyone around them is having these glorious pregnancies and childbirths and they’re suffering.

And so, I think there’s an opportunity for that hospital team to send her on her way with an expectation that and sort of an affirming of her experience in a way that sets her up for as the hand off happens back to her medical home; that she gets the care for her mental and emotional health as well.

Dr. Simon:  Yeah, I’d like to add something there. I completely agree with what Eleni had to say there. And I think another key component is that a solid strong OB hospitalist program and OB hospitalist team has good working relationships with the physicians or midwives in the community. And so, when that patient returns to the community as we talked about; it’s alerting that clinician whether that’s the midwife or a physician in the community about what happened during that delivery process and how the patient may have been impacted. And making sure that they are aware of that and that they are in tuned to that when they see that patient in follow up. Because it has to be teamwork. It has to be a good team hand off from the hospital setting to the outpatient setting.

Eleni:  The other thing that I would add is the other opportunity for sort of sending her on with that continuity of care piece is also the fact that she is at much higher risk for cardiovascular disease as a result of her preeclampsia history. And particularly if it’s a repeated – if it’s multiple pregnancies with preeclampsia or particularly early onset. All of these significantly increase her risk for cardiovascular disease and that’s another are where the hand off of that information back to her care provider needs to happen and she needs to go home knowing this is an area that you will need to be paying more attention to in your life. So, when you’re given a lifestyle modification counseling or advice, when you are encouraged to stop smoking and some other things that we all hear and we all know we need to be doing. The fact is, that the preeclampsia survivor, this message is doubly, triply important for her. Because we do know she’s got a much higher risk for issues associated with her preeclampsia history.

Host:  And just to wrap up here, do you have a good sense for the percentage of women that preeclampsia affects?

Eleni:  So the number varies depending on whose papers you want to read. I would say the broadest range that I’m comfortable talking about is 2 to 8%. And I know that’s a pretty broad range, but the fact is there are probably 200 to 300,000 women a year in the United States who get preeclampsia.

Host:  Well Dr. Simon and Eleni, this has been hugely informative. Thank you so much for your time today. That’s Dr. Mark Simon, the Chief Medical Officer for OB Hospitalist Group and Eleni Tsigas, the CEO of the Preeclampsia Foundation. Thanks for checking out this episode of the Obstetrics Podcast. For the latest information on preeclampsia visit www.preeclampsia.org, that’s P-R-E-E-C-L-A-M-P-S-I-A.org. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll talk next time.