HYPERTENSIVE DISORDERS OF PREGNANCY

In this blog, I’ll be reviewing the trends in hypertensive disorders of pregnancy in the U.S., associated complications, common allegations and defenses specific to hypertensive disorders of pregnancy and recommendations to mitigate risk.

What are Hypertensive Disorders of Pregnancy? 

This umbrella term encompasses gestational hypertension, preeclampsia, preeclampsia with severe features, eclampsia, hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, chronic hypertension and superimposed preeclampsia.   All of these conditions involve blood pressure elevations during pregnancy, and after pregnancy (postpartum). 

Trends in the U.S.:

The American College of Obstetricians and Gynecologists (2022) published a research letter informing readers that hypertensive disorders of pregnancy now affect 8% of pregnancies.  Hypertensive disorders of pregnancy increased from 2.79% in 1989 to 8.22% in 2020 (ACOG, 2022).   This is an average annual percentage change of 3.6%.  Since 2010, U.S. rates of hypertensive disorders of pregnancy and chronic hypertension have been increasing (ACOG, 2022).  This is a significant finding as hypertensive disorders of pregnancy are associated with significant morbidity and mortality.   Hypertensive disorders of pregnancy account for 7.4% of pregnancy-related deaths with as many as 60% of maternal deaths from preeclampsia identified as preventable (AWHONN, 2021). 

Everyone caring for women during pregnancy must be aware of the significance of the disease process, current diagnostic criteria, and management recommendations.  Prompt recognition of the disease, monitoring for complications and timely treatment of hypertension reduces the risk of significant maternal, fetal, and neonatal morbidity.  

Complications from Hypertension in Pregnancy:

Complications include, but are not limited to, placental abruption, disseminated intravascular coagulation (DIC), cerebral hemorrhage, cerebral vascular accident (stroke), hepatic failure and acute renal failure.  Additionally, there is an increased risk of fetal and neonatal death.  Neonatal morbidities include low Apgar scores, seizures, and neonatal encephalopathy (AWHONN, 2021).    

Common Areas of Liability / Common Allegations:

• Failure to accurately diagnose preeclampsia
• Failure to timely treat hypertension / Failure to treat acute severe hypertensive crisis
• Failure to treat preeclampsia
• Failure to advise the patient to seek outpatient or inpatient evaluation and treatment during telephone triage
• Failure of the provider to perform bedside evaluation
• Failure to have a policy in place specific to diagnosis and treatment of hypertensive disorders of pregnancy
• Discharge of the unstable patient

Common Defenses:

• The standard of care was adhered to by the perinatal team
• The mother was non-compliant with the recommended plan of care
• The mother maintained an unhealthy lifestyle before and during pregnancy (patient was overweight pre-pregnancy, patient was a smoker)   
• The mother had pre-existing risk factors
• Documentation reflected timely and appropriate communication between the perinatal team members

Recommendations:

• Implement evidence based national standards and guidelines as they serve as the hallmark of safe, high-quality perinatal care.  Establish a process whereby provider and nursing leadership complete a monthly review of new standards and guidelines published by professional organizations and timely adopt the standards in hospital (inpatient and outpatient) policies. 
• Have policies, procedures, protocols, and algorithms based on national standards and guidelines available to the perinatal service team (accessible in multiple formats – laminated algorithms in care areas, links available on electronic devises, necessary membership to support access).
• Ensure all clinicians and staff are competent in knowledge and skills for the responsibilities they are assigned.  Have a standardized new hire perinatal orientation, and on-going training/simulation specific to diagnosis and management of acute severe hypertensive crisis.
• Keep up with evidence, standards, and guidelines through membership in professional organizations (recommended organizations – AWHONN, ACNM, AAP, ACOG, ASA, SMFM)

References:

ACOG (2022). Trend in hypertensive disorders of pregnancy in the U.S. from 1989 to 2020. 140(1)

AWHONN (2021). Perinatal Nursing, 5^th ed. Wolters Kluwer

P.S. Comment and share your experience with a case involving maternal, fetal or neonatal complications associated with a hypertensive disorder of pregnancy.