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Clinicians wait too long before diagnosing and treating preeclampsia, a hesitance that can be costly, according to Mark Zakowski, MD, chief, obstetrical anesthesiology at Cedars-Sinai Medical Center in Los Angeles.
Zakowski, one of two anesthesiologists on the Preeclampsia Task Force for the California Maternal Quality Care Collaborative (CMQCC), said the most common frustration he's had over the years with preeclampsia cases is clinician denial.
"Medical professionals don't want their patient to have it [preeclampsia], so they downplay, 'Oh, they're just anxious,' 'They have white-coat hypertension,' or when the patient has had a couple of contractions and blood pressure is 150/90, they say 'Oh they're just in pain, don't worry about it.'"
"They were denying it because there wasn't a full expression of the disease," Zakowski told MedPage Today.
"You have to have a very low index of suspicion," Zakowski said. Even if most people have elevated blood pressure at the moment they are having contraction pain, Zakowski said, "Once you have one blood pressure in the preeclampsia range, the onus is on you to prove that it's not preeclampsia."
The diagnostic criteria are changing to shift emphasis to blood pressure, according to Zakowski, who said "Even one of the classic hallmarks of preeclampsia, proteinuria, as one of the criteria may be dropped."
Zakowski said every blood pressure measurement at every visit is important and must be treated as such in order to prevent end-organ damage including cerebrovascular accidents.
According to the CMQCC report, the primary contributor to preeclampsia associated complications is delay in MD evaluation. Other factors include: delays in medical care, missed triggers, delays in diagnosis, delays in treatment, transfer difficulties, and location of care.
"There's definitely a push to have earlier treatment of blood pressure once it's found to have increased," Zakowski said. "And you can't even get the proper treatment if you don't have the proper diagnosis, so there's an increased sensitivity and awareness."
To improve diagnosis and insure swifter treatment, Zakowski helped develop a toolkit for clinicians to better diagnose and manage cases.
"A main goal of the toolkit, which is really get the blood pressure down to a safe level so you don't burst an aneurysm or get bleeding into the head, and by early consultation with others who may have more experience, expertise, or even just familiarity with some of the alternative medicines -- turn to someone else for some more help early," he said.
The criterion changed from elevated blood pressure measured at 6-hour intervals to treating elevated blood pressure with anti-hypertensive medication within an hour. Clinicians "need to recheck elevated blood pressure within 15 minutes to make the diagnosis of acute hypertension and initiate treatment right away," Zakowski said.
"Although in the textbook, it may say: 'this diagnosis has A, B, C, and D.' [But] you don't always have full expression in all patients, so you need to be sensitive to any of the criteria helping you make the diagnosis. You may not have all aspects of it [preeclampsia], so you need to have a low sensitivity in order to make the diagnosis," he added.
Postpartum preeclampsia -- labile hypertension -- is another focus, which requires prompt follow-up if a patient has had elevated blood pressure to make sure the blood pressure remains under control.
Zakowski said too many patients leave hospital and then come back to the ER, so the toolkit has a section for ER docs to identify late-onset preeclampsia and hypertension to prevent a postpartum event.
From the American Heart Association: