Clinical audit of intensive care unit admission relating to hypertensive disorders of pregnancy / 中华围产医学杂志

ABSTRACT

Objective To assess the current practice in managing hypertensive disorders of pregnancy (HDP) and provide possible interventions to improve the quality of care.MethodsA checklist was developed based on Chinese Medical Association's guideline on HDP. A criteria-based audit was conducted on 66 HDP patients who were admitted to the Intensive Care Unit (ICU) of Nanjing Drum Tower Hospital,The Affiliated Hospital of Nanjing University Medical School between January 1, 2014 and December 31, 2016. The quality of care during antepartum and hospitalized period were evaluated, and patient factors were also considered. We also collected data on patients' demographics, complications of HDP, acute physiology and chronic health evaluation (APACHE)Ⅱ score and duration of hospital stay.T or Mann-WhitneyU test orChi-square test was performed. Results(1) From 2014 to 2016, the number of deliveries in Nanjing Drum Tower Hospital was 18573, with 1561 cases (8.4％) of HDP. Among the 66 cases being audited, 44 (66.7％) were preeclampsia; 16 (24.2％) were preeclampsia complicated by chronic hypertension; six (9.1％) were eclampsia; no maternal death was reported. (2) Complications of HDP in this study included heart failure (17 cases, 25.8％), hemolysis, elevated liver enzyme levels, low platelet count (HELLP) syndrome (15 cases, 22.7％), anemia and/or thrombopenia requiring transfusion (12 cases, 18.2％), renal dysfunction (seven cases, 10.6％), eclampsia (six cases, 9.1％), pulmonary edema/acute respiratory distress syndrome (five cases, 7.6％), placenta abruption (four cases, 6.1％), cerebral venous and sinus thrombosis (two cases, 3.0％), cerebral hemorrhage (one case, 1.5％) and hepatic rupture (one case, 1.5％). Their APACHEⅡ score was 9.0±3.9. The duration of ICU and hospital stay was 2 (1-30) d and 8 (4-32) d, respectively. (3) Compared with the gravidas who registered during antenatal care, those without registrations were older [(33.0±6.0) vs (29.1±5.4) years old,t=-2.616], having less antenatal visits [2 (0-4) vs 5 (2-10) times, Z=110.000] and higher blood pressure on admission [(177.0±24.1) vs (155.5±24.6) mmHg of systolic blood pressure (t=-3.322), and (116.4±14.6) vs (108.0±18.7) mmHg of diastolic blood pressure (t=-3.013, 1 mmHg=0.133 kPa)], and only a few of them were nulliparas [23.8％(5/21) vs 71.1％(32/45),χ2=13.006] (all P<0.05). (4) Among the 66 cases, seven (10.6％) had preeclampsia history, but none of them received aspirin for HDP prevention; 21 (31.8％) did not have regular testing of blood pressure during antenatal check; 24 (36.4％) did not receive proper antenatal evaluation when hypertension was identified. (5) After excluding 20 cases directly admitted upon the first diagnosis of HDP, the rest 46 were managed in the outpatient department. Eighteen of them (39.1％) did not have blood pressure monitoring and 26 of them (56.5％) did not have a regular test of hemoglobin, platelet, urine protein, liver or renal function. (6) Twenty-nine gravidas (43.9％) suffered a delay in referral or admission. (7) All gravidas received magnesium sulphate administration. Thirty-three cases with severe hypertension (systolic blood pressure≥160 mmHg or diastolic blood pressure≥110 mmHg) were given antihypertensive drugs with satisfactory blood pressure control. Thirty-six cases with living fetus (26-34+6 gestational weeks) received antenatal dexamethasone. Termination of pregnancy was delayed in three cases after admission.ConclusionsThe management of HDP is not good enough in patients' education, screening for high-risk population, early diagnosis and antenatal care. Quality improvement efforts should be focused on strengthening patient education, training of doctors in primary and secondary hospitals, implementing protocols on antepartum care of preeclampsia and establishing a referral system for patients with severe obstetric complications.