RESUMO
BACKGROUND: An institutional standardized, nurse-initiated protocol was implemented to improve the recognition of and response to perinatal hypertensive emergency. OBJECTIVE(S): The primary aim was to evaluate if the rate of guideline-based treatment of perinatal hypertensive emergency improved with implementation of the protocol. STUDY DESIGN: This quality improvement initiative was developed by a multidisciplinary team and consisted of clinician and nursing education and the implementation of a standardized, nurse-initiated severe hypertension protocol. The project took place in three phases: pre-implementation (July 2020-October 2020), implementation (November 2020-June 2021), and sustainment (July 2021-May 2022). The primary aim was to increase guideline-based treatment of hypertensive emergency among pregnant and postpartum persons. Guideline-based treatment was defined as repeat blood pressure within 30 minutes of severe hypertension to diagnose hypertensive emergency, antihypertensive medication administration within 30 minutes of diagnosis, and appropriately timed repeat blood pressure following treatment. Process measures included time to confirm the diagnosis, initiate the protocol, antihypertensive medication administration, repeat blood pressure after antihypertensive medication administration, and administration of a secondary dose as appropriate. Balancing measures included maternal intensive care unit admission, clinically significant maternal hypotension, fetal demise, neonatal birthweight, and Apgar <7 at 5 minutes. Data were evaluated using between-subjects statistics and a run chart was developed to assess relationship between the protocol and changes in guideline-based treatment over time. RESULTS: Overall, 503 hypertensive emergency encounters were identified during the project period (98 [20%] pre-implementation, 172 [34%] implementation, 233 [46%] sustainment). There were higher rates of persons with chronic hypertension and who self-identified as non-Hispanic Black race in the sustainment phase compared to the other phases. Guideline-based treatment increased from 18.4% pre-implementation to 75.1% in sustainment (p<0.001). Each component of guideline-based treatment also improved significantly from pre-implementation to sustainment (p<0.001). No episodes of clinically significant maternal hypotension occurred in any phase. There were four maternal intensive care unit admissions and three fetal demises during the initiative; none were related to hypertensive emergency. CONCLUSION(S): The nurse-initiated protocol for treatment of hypertensive emergency significantly increased guideline-based treatment of perinatal hypertensive emergency, reduced time to diagnose and treat hypertensive emergency, and increased the number of patients receiving treatment when indicated. This protocol was pragmatic, utilizing resources already available on obstetric units. Use of similar protocols may be considered at institutions providing obstetric care to improve recognition of and response to hypertensive emergency which may decrease maternal and neonatal morbidity and mortality related to hypertensive emergency.
RESUMO
In this narrative review, we describe evidence regarding the associated risks, benefits, and cost effectiveness of postpartum complete salpingectomy compared with partial salpingectomy. Permanent contraception can be performed via several methods, but complete salpingectomy is becoming more common secondary to its coincident benefit of ovarian cancer risk reduction. Small prospective studies and larger retrospective cohort studies have demonstrated the feasibility and safety of complete salpingectomy in the postpartum period. Additionally, multiple cost-effectiveness analyses have demonstrated the cost effectiveness of this method secondary to ovarian cancer reduction over the life span. Although future larger cohort studies will allow for more precise estimates of the effect of complete salpingectomy on ovarian cancer risk and incidence of rare complications, current data suggest that complete salpingectomy should be offered to patients as a method of permanent contraception in the postpartum period.
