Fatal Consequences of Mismanaged Postpartum Hypertension

Description

Untimely diagnosis and treatment of a postpartum patient’s preeclampsia and hypertension contributed to a stroke and her subsequent death.

Key Lessons

• Inadequate patient assessment and management resulted in premature discharge.
• Evidence-based guidelines for discharge criteria and follow-up of post-partum hypertension, for example, from The American College of Obstetricians and Gynecologists (ACOG), should be embedded into institutional protocols.
• Policies for addressing postpartum patients with hypertension presenting to the emergency department (ED) should be developed in collaboration with the obstetrics team.

Clinical Sequence

A multiparous patient with a history of preterm delivery, fibroids, and hypertension received routine prenatal care and had an uncomplicated pregnancy. She delivered a full-term baby via repeat caesarean section without complications and was discharged home three days after delivery.

One week later, she presented to the ED with complaints of a severe headache. Her blood pressure (BP) on admission was 183/98. The triage nurse documented that the assessment was within normal limits, despite the patient describing her headache as 10 out of 10 on the pain scale.

She was evaluated by a physician assistant (PA) who recommended admission. The PA contacted the on-call obstetrician, who did not concur with the recommendation for inpatient admission. The patient was treated in the ED with medication for her BP without improvement. After consulting the ED physician, the PA was advised to contact the OB team. The PA reported the patient had a BP of 192/92 and a nine out of 10 pain level. She was admitted for observation under the OB team’s care. No OB history or physical was recorded, though admission orders were entered. Her BP improved with medication, and shortly after admission, her severe headache was relieved by hydromorphone. Hours later, her headache recurred at a five out of 10 severity, but no BP or intervention was documented.

The obstetrician discharged the patient the next day, documenting stable blood pressure readings and prescribing a beta-blocker and hydromorphone to be administered at home. After receiving discharge instructions, the patient complained again of a headache rated five out of 10, which was treated with hydromorphone. A repeat BP measurement before discharge was 126/76.

Several hours later, Emergency Medical Services (EMS) brought the patient back to the ED unresponsive and with a BP of 193/94. A computed tomography (CT) scan revealed a severe hemorrhagic stroke. The patient was intubated and transferred to a tertiary care facility, where she passed away two days later.

Allegation

Defendants included the obstetrician, ED attending physician, PA, ED RN, and inpatient RN. The patient’s family alleged the providers failed to properly manage postpartum preeclampsia, which led to her stroke and death.

Disposition

This case was settled in the high range (> $1M).

Clinical Analysis

• Failure to appreciate and reconcile signs and symptoms of postpartum hypertension
  Nurses caring for postpartum patients, both in the emergency department and inpatient units, must be able to detect subtle signs and symptoms potentially indicating worsening postpartum hypertension. This includes frequent BP monitoring and assessment of headache pain.
• Failure to adequately evaluate the patient’s headache prior to discharge and treating with opioids
  Before discharging a postpartum patient experiencing symptoms of headache and increased BP, clinicians should evaluate for possible differential diagnoses. Failing to rule out other diagnoses can delay care and increase the risk of adverse events.
• Pain medication prescribed at discharge masked the patient’s headache symptoms
  Opioids are not recommended as a first-line of treatment for postpartum headache relief. While opioids can relieve pain, they do not address the underlying cause of the headache. Collaborating with the pharmacist on the health care team can help identify a more appropriate analgesic to treat these patients.

Discussion Questions

1. What is your institution’s policy for inpatient monitoring and treatment of postpartum hypertension?
2. What are your institution’s discharge criteria for patients experiencing postpartum hypertension?
3. Do your discharge instructions clearly specify the circumstances under which patients should contact their obstetrician, as well as the appropriate timing for doing so?
4. Do your ED and OB services collaboratively develop policies and protocols for evaluation and treatment of postpartum hypertension?
5. Does your institution have an escalation policy for conflict resolution in patient care?

Resources

• Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin Number 222
• Postpartum Headache
• Hypertension in Pregnancy and Postpartum: Current Standards and Opportunities to Improve Care
• Best Practices for Managing Postpartum Hypertension
• A review of clinical practice guidelines on the management of preeclampsia and nursing inspiration