Hypertensive disorders are a common complication of pregnancy and a leading cause of maternal and neonatal morbidity and mortality. Preeclampsia is estimated to affect 2% to 8% of pregnancies worldwide, and rates in the United States increased 25% between 1987 and 2004.[1] While the exact cause is unknown, increases in the prevalence of maternal obesity and advanced maternal age are known contributors to this worsening perinatal problem. In an effort to improve outcomes, national collaborations involving the American College of Obstetricians and Gynecologists, the Alliance for Innovation on Maternal Health, and state perinatal organizations have developed safety bundles for the management of hypertensive disorders in pregnancy and encourage their implementation. OB/GYN hospitalists are often the first physicians to diagnose and treat pregnant and postpartum women with hypertensive disorders and can be advocates for standardized, evidence-based management in their hospitals.

Knowledge

OB/GYN hospitalists should be able to:

• Define and differentiate among the hypertensive disorders in pregnancy.
• Describe the technique for accurate blood pressure measurement.
• Describe the pathophysiology of pregnancy-associated hypertensive disorders.
• Discuss the differences between essential and secondary chronic hypertension in pregnant women.
• Describe the recommended evaluation for defining the underlying hypertensive mechanism and evaluating the extent of end-organ damage in patients with chronic hypertension.
• List maternal risk factors for developing a hypertensive disorder in pregnancy.
• Identify maternal and fetal complications associated with hypertensive disorders in pregnancy.
• Discuss the diagnostic workup for preeclampsia, including the recommended laboratory tests and the physiologic impact of preeclampsia on their values.
• Discuss the fetal surveillance recommended for various hypertensive disorders.
• Discuss the recommendations for timing of delivery in the setting of various hypertensive disorders of pregnancy.
• List antihypertensive agents that can be used for chronic or acute treatment of hypertension, including dosage, indications, contraindications, and adverse effects.
• List antihypertensive medications that are contraindicated in pregnancy and explain why.
• Describe the use of magnesium sulfate, including indications, contraindications, dosing, adverse effects, and how to monitor for and treat toxicity.
• Discuss the management of an eclamptic seizure.
• List the indications for low-dosage aspirin for the prevention of preeclampsia.
• Discuss the recommendations for assessing women with a history of preeclampsia for future risk of cardiovascular disease.

Skills

OB/GYN hospitalists should be able to:

• Elicit a thorough and relevant medical history, with emphasis on identifying potential complications of hypertensive disorders of pregnancy.
• Perform an appropriate physical examination, assessing for pulmonary and cardiac status, right upper-quadrant or epigastric tenderness, uterine tone, edema, and reflexes.
• Perform an assessment of fetal well-being with specific consideration to the fetal complications resulting from hypertensive disorders in pregnancy.
• Order appropriate laboratory tests and imaging studies to diagnose hypertensive disorders in pregnancy.
• Synthesize history, physical examination findings, and imaging and laboratory test results to formulate an evidence-based diagnosis and treatment plan for women with a hypertensive disorder in pregnancy.
• Engage consultants and coordinate a multidisciplinary approach, including the patient, those who support the patient, nursing staff, primary OB/GYN provider, maternal-fetal medicine specialists, and critical care specialists, when indicated.
• Initiate the appropriate pharmacologic interventions to reduce maternal and fetal morbidity and mortality, including but not limited to the appropriate timely use of antihypertensive therapy and seizure prophylaxis.
• Counsel patients with acute-onset, severe-range blood pressure who require expeditious delivery regarding recommended management, including maternal and fetal risks and benefits.
• When appropriate, stabilize patients for transfer to higher level of care and facilitate this transfer.
• Diagnose and manage an eclamptic seizure.
• Diagnose and manage magnesium toxicity.
• Communicate with patients and families regarding hypertensive disorders and their impact on current and future pregnancies.
• Educate postpartum patients and families on the appropriate short- and long-term follow-up after a diagnosis of a hypertensive disorder in pregnancy.
• In the medical record, appropriately document the medical history, physical examination findings, relevant test results, and discussion with the patient regarding the diagnosis, care options, and management plan.

Self-Awareness and Collaborative Attitudes

OB/GYN hospitalists should be able to:

• Follow evidence-based protocols for the management of hypertension in pregnancy.
• Collaborate and communicate effectively within a multidisciplinary team, including the patient, those who support the patient, nursing staff, primary OB/GYN provider, maternal-fetal medicine specialists, and critical care specialists, to optimize outcomes and the patient experience.
• Initiate consultations and/or transfers to a higher level of care when indicated.
• Demonstrate awareness of and ability to address emotional concerns related to the well-being of the patient and fetus.
• Respect the patient’s desires, values, and autonomy.

System Organization and Improvement

OB/GYN hospitalists should be able to:

• Lead, coordinate, and/or participate in efforts to ensure the appropriate and timely diagnosis and management of hypertensive disorders in pregnancy in all relevant departments, including the emergency department.
• Lead, coordinate, and/or participate in initiatives to ensure that patients who are discharged from triage or other settings with a diagnosis of a hypertensive disorder in pregnancy have appropriate follow-up with their primary OB/GYN provider.
• Lead, coordinate, and/or participate in initiatives to ensure that patients have knowledge of signs and symptoms of hypertensive disorders in pregnancy.
• Lead, coordinate, and/or participate in safety drills and simulation exercises to encourage a multidisciplinary approach to the management of severe hypertension and its complications.
• Lead, coordinate, and/or participate in state-wide collaborative efforts to address maternal hypertensive morbidity and mortality.
• Implement processes to track and improve the quality of care regarding hypertensive disorders, such as timely treatment of severe hypertension.
• Perform and/or support institutional research that enhances the understanding of hypertensive disorders of pregnancy.

References