The Performance Gap

Global maternal deaths have fallen 44% since 1990 but still over 303,000 women die each year from complications related to pregnancy, delivery, or within the first six weeks after delivery \cite{world44a}. A majority of deaths (64%) occur from the day of delivery through 41 days postpartum\cite{Creanga_2015}. That equates to about 830 women dying every day, 550 occurring in sub-Saharan Africa, 180 in Southern Asia, and 5 in developed countries \cite{world2016global}.
Within the United States it is estimated that approximately 600 women die each year \cite{ob15}; 14.0 per 100,000 live births \cite{world2015trends}. While that number seems to pale in comparison on the global scale the US ranks 46th in the world for maternal mortality \cite{ob17}. Of all industrialized countries, the US lags behind Kazakhstan, Libya and Qatar and is one of only 13 countries whose rates have continued to decline instead of improving over the last 25 years \cite{ob18}.
A 2015 report by the United Nations (UN) agencies and World Bank Group, Trends in Maternal Mortality: 1990 to 2015, was generated to gauge whether the UN’s Millennium Development Goals would be reached.5 The 2015 target was to reduce maternal mortality by three-quarters. Only 9 of the 100 countries participating reached the 2015 goal so the new target is to reduce global average maternal death rates below 70 per 100,000 live births by the year 2030, with no country above 140 per 100,000 live births.1
The reasons for the overall increase in maternal mortality within the US are unclear. Delaying childbearing and assisted reproductive technology (ie: in-vitro fertilization) have given rise to older mothers with an increased risk of complications than younger women \cite{Jolly_2000,Bewley_2005}. Additionally, the obesity epidemic gives rise to chronic conditions such as hypertension, diabetes, and chronic heart disease increase the risk of complications during pregnancy \cite{centers2015pregnancy,Kuklina_2009,Albrecht_2010,Kuklina_2012}.
Over a third of maternal deaths in the US are preventable, 40% could be avoided if women had access to quality care \cite{Berg_2005}. Most notably, black women have a 3 to 4-fold increased risk of death due to pregnancy compared to any other race or ethnicity \cite{creanga2014racial}. The reasons are extremely complex and not well documented. Moreover, severe maternal morbidity is much more prevalent and preventable, affecting tens of thousands of women each year \cite{Callaghan_2012,Callaghan_2008}.

Hypertension and Preeclampsia

Hypertensive disorders occur in 12-22% of all pregnancies and are one of the leading conditions that impact women during pregnancy \cite{19173021}. Hypertension may be pre-existent, may be induced by the pregnancy or both may co-occur \cite{25298602}. Approximately 15-17% of all maternal mortality is caused by hypertensive disorders which include: chronic (preexisting) hypertension, gestational hypertension, preeclampsia, severe preeclampsia, eclampsia and HELLP (Hemolysis, Elevated Liver Enzymes, Low Platelet Count) \cite{11072961}. The causes of pregnancy-induced hypertension and the risk factors are still being widely studied. However, hypertension among pregnant women in the US has increased significantly over the last two decades due to increased rates of obesity and diabetes.(Leddy 2008) During pregnancy, hypertensive disorders not only affect the mother but also may contribute to significant neonatal morbidity and mortality \cite{21547086}
Chronic hypertension during pregnancy is defined as blood pressure (BP) (mmHg) of ≥140/90 mmHg, prior to the 20th week of pregnancy and leads to complications in 5% of all pregnancies \cite{17309919,druzin2013preeclampsia,Yanit_2012}. Preeclampsia is defined as a BP of ≥160/110 mmHg and associated with proteinuria ≥5g per day. Gestational hypertension is defined as new hypertension associated with a systolic BP of ≥140 mmHg or diastolic BP ≥90 mmHg, or both presenting at or after 20-weeks gestation without proteinuria or other features of preeclampsia.6 Preeclampsia is considered severe when the condition affects multiple organs, such as: thrombocytopenia (platelet count ≤100,000/uL), pulmonary edema, or oliguria (≤500ml per day). Mild preeclampsia is characterized by an elevated BP ≤160/120 with proteinuria ≥300mg but less than 5g per day \cite{Sibai_2003}. Studies show that between 50-70% of deaths due to severe preeclampsia are preventable \cite{SCHECHTER_1991,world2011recommendations,17904961}. The leading patient factors among maternal deaths due to preeclampsia were: delays in seeking care (42%), presumed lack of knowledge regarding the severity of a symptom or condition (39%) and underlying medical condition (39%) \cite{Main_2015}.
In the United States, the direct cost burden of preeclampsia for the first 12 months after delivery is $2.18 billion. That cost is split between maternal healthcare costs, equating to $1.03 billion, and $1.15 billion attributed to infants born to preeclamptic mothers \cite{Stevens_2017}

Prevention

No clear strategies have emerged to prevent the onset of preeclampsia though some, like lose dose aspirin taken daily starting at the end of the first trimester have been shown to reduce preeclampsia among high risk women. Once diagnosed with preeclampsia it is important to recognize worsening signs and symptoms and prevent eclamptic seizures and stroke.
In the past, the focus was placed on the prevention of eclamptic seizures, which is associated with an increase in both neonatal and maternal morbidity and mortality. Delay in treating hypertension is the primary cause of concern. The majority of women who die of severe preeclampsia die from stroke \cite{Bushnell_2011}. Stroke can only be prevented with the rapid infusion or delivery of antihypertensive medications. This is the key to saving lives from complications of severe preeclampsia is administering an antihypertensive medication within 60 minutes. are forefront to prevent complications due to preeclampsia. Eclamptic seizures can be prevented and treated through the administration of magnesium sulfate \cite{Sibai_2004,2002,12804383,Martin_2005}. Unlike the relatively straightforward prevention of eclamptic seizures, there is a gap in knowledge and application of therapeutic interventions for stroke prevention through controlled BP. Typically, treatment of systolic BP of ≥160, and/or diastolic BP ≤105 has been recommended \cite{KAYEM_2011}. In practice, clinicians institute therapies at a lower level of systolic and/or diastolic blood pressures.
The most important intervention in the treatment for preeclampsia/eclampsia is delivery of the fetus and placenta. The phrase “delivery is the cure” is widely accepted however in many cases preeclampsia/eclampsia may continue for a variable amount of time after delivery. For this reason, mothers post-delivery should continue to be evaluated if they were preeclamptic. Serious clinical outcomes can continue postpartum for days and even weeks \cite{Chescheir_2015}.
Early recognition and timely treatment of preeclampsia is a critical factor in reducing maternal morbidity and mortality.

Leadership Plan

Practice Plan

The Council on Patient Safety in Women’s Health Care developed comprehensive bundles and list of resources that applies to the prevention of harm from severe preeclampsia. The bundles are a roadmap for hospitals to use in the prevention of harm.

Technology Plan

Suggested practices and technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. As other options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org.

Metrics

Topic 1

Severe Maternal Morbidity among Preeclampsia Cases

Outcome Measure Formula

Numerator: Among the denominator, cases with any SMM code
Denominator: All mothers during their birth admission, excluding extopics and miscarriages, with one of the following diagnosis codes:

Metric Recommendations

Direct Impact: All Pregnant Patients
Lives Spared Harm: