By Eleni Tsigas, Executive Director, Preeclampsia Foundation

States and healthcare systems that are making a concerted effort to respond to the alarming maternal mortality and morbidity rate in this country are discovering something important. Preeclampsia and hypertensive crises in pregnancy are frequently cited in cases where neglect, delayed diagnosis, and inadequate management contributed to poor outcomes. (Main, 2015)

Protocols for early warning systems, including a list of criteria that indicate urgent bedside evaluation, have been created to facilitate more timely recognition and more effective therapeutic intervention. While we don't yet truly understand the entire cause of preeclampsia and there is no sure fire prevention or treatment, there is much that can be done with what we do know today.

Numerous guidelines, toolkits, and bundles have been created specifically to address the preventable morbidity and mortality associated with preeclampsia. (ACOG, 2103). While somewhat an oversimplification, it really boils down to just five things:

1. Recognize the symptoms
2. Control blood pressure
3. Prevent seizures
4. Deliver at the optimal time
5. Ensure postpartum surveillance

Maternal Early Warning Systems (MEWS), now operationalized as a bundle, cite the following criteria as requiring immediate bedside evaluation (Mhyre, 2014):

The current definition of preeclampsia includes blood pressure of 140/90 or greater and protein in the urine OR one or more indications of other organ failures (thrombocytopenia, liver, renal, pulmonary, cerebral or vision). (ACOG, 2013). HELLP syndrome, a particularly dangerous variant, often presents without alarming blood pressures, but epigastric pain, vomiting and flu-like symptoms may be the hallmarks of the liver failure usually underway. Given this, it's easy to see why MEWS is optimally organized to ensure that women like Lauren Bloomstein do not die from preeclampsia.

What's less obvious is the role of patients and their family members in this MEWS world. The Joint Commission issued Sentinel Event Alert #44 in January 2010 and, among several preeclampsia-specific calls to action to address preventable maternal death, noted the need to identify specific triggers for responding to changes in the mother's vital signs and clinical condition and to use protocols for responding to these changes. One of those is to inform the patient and family how to seek assistance when they have concerns about a patient's condition. (This and other protocols have now been codified and there are some excellent implementation practices provided by the Council on Patient Safety in Women's Healthcare.)

But how is a patient to know what she should be alert to and consider worthy of engaging her providers?

This is where deliberate, effective and, where possible, evidence-based patient education tools and techniques become critical. Lamaze instructors are in an excellent position to partner on these life-saving strategies. The Preeclampsia Foundation advocates for patient education to be offered throughout the prenatal care period and upon discharge.

Women must be taught the symptoms of preeclampsia (see below), understanding that these do not lead to a certain diagnosis, but are causes for immediate follow up. If she's in the hospital or birth center before, during, or after childbirth, she or her family must advocate for immediate bedside assistance to evaluate her vital signs, call for blood work or further testing, and determine if her care must be escalated. Hypertensive disorders like preeclampsia and HELLP syndrome can worsen quickly!

Symptoms of Preeclampsia or HELLP Syndrome

• A headache that won't go away
• Visual disturbances (seeing spots or auras)
• Epigastric pain (upper right quadrant)
• Nausea/vomiting (2H pregnancy)
• Sudden weight gain
• Breathlessness (difficulty breathing)
• Swelling of the face or hands
• "Just not feeling right"; unexplained "anxiety"

Adult learning techniques and evidence-based tools like the Preeclampsia Foundation's tear sheet, clinic poster, and video can aid care providers, childbirth educators, doulas. More important than any tool is the attitude that care providers have toward patient education. It should be deemed as important at all levels of healthcare (administration to med techs). And it should reflect the fact that all of us learn differently, with varying amounts of health literacy and different perceptions of our roles within the healthcare environment (i.e., is the doctor the defacto expert or does the patient have a proactive role to play?). This is an opportunity early in a woman's life course to empower the mother to understand and become an active participant in her and her new baby's health, a lifelong skill, and increasingly a necessity as we are called to navigate a complex healthcare system.

More information about Maternal Early Warning Signs, and especially patient education techniques and tools, will be offered in a free webinar on Tuesday, May 30, at 12 pm ET, provided by the Council on Patient Safety in Women's Healthcare. Lamaze Certified Childbirth Educator Jessica Deeb, MS, RN, WHNP-BC, IBCLC, LCCE, will join me as co-presenter. Registration is available here. Childbirth educators and other birth professionals should consider signing up to attend, increasing awareness for professionals and families

References

Main, Elliott K., McCain, Christy L., Morton, Christine H., Holtby, Susan, Lawton, Elizabeth S., "Pregnancy-Related Mortality in California: Causes, Characteristics, and Improvement Opportunities." Obstetrics & Gynecology. April 2015.

Mhyre, Jill M., D'Oria, Robyn, Hameed, Afshan B., Lappen, Justin R., Holley, Sharon L., Hunter, Stephen K., Jones, Robin L., King, Jeffrey C., D'Alton, Mary E., "The Maternal Early Warning Criteria: A Proposal from the National Partnership for Maternal Safety." Obstetrics & Gynecology. October 2014.

"Hypertension in Pregnancy." The American College of Obstetricians and Gynecologists. 2013.

About Eleni Z. Tsigas

Eleni Z. Tsigas is the Executive Director of the Preeclampsia Foundation. As a preeclampsia survivorherself, Eleni is a relentless champion for the improvement of patient and provider education and practices, for the catalytic role that patients can have to advance the science and status of maternal-infant health, and for the progress that can be realized by building global partnerships to improve patient outcomes.

She has served as a technical advisor to the World Health Organization (WHO) and participated in the Hypertension in Pregnancy Task Force created by the American College of Obstetricians and Gynecologists to develop the national guidelines introduced in 2013, as well as a similar task force for the California Maternal Quality Care Collaborative (CMQCC). Eleni also serves on behalf of the Preeclampsia Foundation as a voting member of the Council on Patient Safety in Women's Health Care, the Patient Advisory Board of IMPROvED (IMproved PRegnancy Outcomes via Early Detection), Ireland, and the Technical Advisory Group and Knowledge Translation Committee for PRE-EMPT (funded by the Bill & Melinda Gates Foundation). Eleni is frequently engaged as an expert representing the consumer perspective on preeclampsia at national and international meetings and has been honored to deliver keynote addresses for several professional healthcare providers' societies.

Eleni has collaborated in numerous research studies, has authored invited chapters and papers in peer-reviewed journals, and is the Principal Investigator for The Preeclampsia Registry.