by Tammie Smeltz
“Clinician needs in times of uncertainty surrounding maternal-fetal medicine” is ECRI’s No. 3 concern for patient safety in 2023. On June 24, 2022, the Supreme Court overruled Roe v. Wade leaving individual states with the full power to regulate reproductive rights. ECRI recognized this issue as a significant concern for providers who practice in states that have either prohibited or limited access to abortion.
On June 23, 2023, Governor Hochul signed into law Chapter 138 of the Laws of 2023. This law provides certain legal protections for reproductive health service providers who provide legally protected health activities including protection from extradition, arrest and legal proceedings in other states relating to such services; and restricts the use of evidence relating to the involvement of a party in providing legally protected health activity to persons located out-of-state. This law is effective June 23, 2023.
Since this law is newly enacted, it is important to recognize that its application will be subject to judicial interpretation. Accordingly, it is important to follow MLMIC for updates on this new law.
In addition to patient safety and clinician concerns, there are other issues providers face when treating maternal-fetal patients. One of them is hypertension and preeclampsia.
The remainder of this blog will discuss the risk of hypertension and preeclampsia during pregnancy, share a brief analysis of obstetrical claims and provide risk management tips to protect yourself from litigation.
Hypertension and Preeclampsia in Pregnancy
According to the American College of Obstetrics and Gynecology, chronic hypertension is present in .9 -1.5% of pregnant women. The rate of maternal chronic hypertension increased by 67% from 2000 to 2009, with the largest increase among Black women (87%). This trend is largely secondary to obesity and increasing maternal age. According to the Centers for Disease Control (CDC), older women, as well as Black women, are at a higher risk of developing hypertensive disorders during pregnancy. However, because this condition can affect even the healthiest of patients, as recently seen with Olympic athlete Tori Bowie, it is imperative for providers to monitor and address elevated blood pressure during each prenatal visit.
There are several additional factors that place patients at a higher risk for preeclampsia, such as a history of preeclampsia from a prior pregnancy, chronic hypertension, Type 1 or Type 2 diabetes prior to pregnancy, kidney disease or history of autoimmune disorders. Current research suggests there are non-biological risk factors for preeclampsia, such as inequities in access to prenatal care, chronic stressors that can influence well-being generally and lower socioeconomic status.
When assessing prenatal patients, in addition to elevated blood pressure, other symptoms to look for may include proteinuria, thrombocytopenia, elevated liver enzymes, headaches, vision changes, upper belly pain or shortness of breath. As a provider, it is prudent to explore any of the above symptoms during pregnancy.
Claims Analysis
MLMIC Insurance Company analyzed claims closed from 2013 through 2017 and resulting in an indemnity payment of one million dollars or more. The analysis of claims resulting in death revealed female claimants died more frequently and at a younger age than male claimants. A female of childbearing age (21-45 years of age) was identified as a claimant almost twice as often as a male in the same age group.
The analysis found that OB/GYN was the top specialty, making up 24% of the claims that were reviewed.
Regarding hypertension and preeclampsia, the study showed that 55% of the cases included eclampsia occurring from the prenatal to post-partum period. However, only 41% of the patients were identified as high-risk. In 82% of the files reviewed, blood pressure increased over time, and 31% of the time the provider failed to identify or follow up on known risk factors.
Because of these results, MLMIC has identified hypertension and preeclampsia in pregnancy as major concerns for our insureds in the field of maternal-fetal medicine.
How to Protect Yourself from Liability
As of July 1, 2020, the Joint Commission implemented six new policies to help reduce the likelihood of harm related to maternal severe hypertension and preeclampsia. The policies are focused on developing written evidence-based procedures, drills/debriefs, case reviews and education not only for staff and providers but also for patients and families.
In accordance with these new policies, MLMIC recommends the following when treating obstetrical patients:
- Review your office’s policies and procedures regarding screening for hypertension annually and create specific guidelines to address this condition.
- Educate all providers and staff in screening pregnant patients for hypertension and ensure that screening tools and guidelines are placed in all exam rooms.
- Educate patients and their families about the risk factors, as well as signs and symptoms of preeclampsia, including during the post-partum period.
- Monitor blood pressure at each visit and ensure the readings are discussed between the provider and staff. Clear two-way communication channels are essential when implementing a treatment plan for hypertension.
- Provide educational resources to patients and their families and suggest at-home blood pressure monitoring when appropriate.
- For patients screened as a moderate risk for developing preeclampsia, consider daily low dose aspirin, initiated between 12-28 weeks gestation (optimally before 16 weeks) and continue until delivery. Also, monitor for signs and symptoms of hypertension at each prenatal visit.
- For patients screened as high risk for developing preeclampsia, a urine dipstick or protein/creatine ratio or 24-hour urine at the first visit is recommended. Urine dipsticks should be completed at every subsequent visit with a protein/creatinine ratio or 24-hour urine if the dipsticks exceed 1+. Consider daily low dose aspirin, initiated between 12-28 weeks gestation (optimally before 16 weeks) and continue until delivery. Monitor for symptoms of hypertension regularly and conduct focused histories at every visit after 20 weeks gestation looking for symptoms such as headache, visual changes, abdominal pain, nausea/vomiting, swelling or high weight gain over a short period of time.
According to the New York Times, the FDA approved a blood test that can identify pregnant women who are at risk for developing preeclampsia. The test will be available for pregnant women hospitalized from 23 to 35 weeks gestation with elevated blood pressure. The test will be able to indicate, with 96% accuracy, which patients will not develop preeclampsia within the next two weeks. Two-thirds of the patients with a positive result will progress to severe preeclampsia during that period.
MLMIC offers an array of educational programs addressing maternal-fetal medicine, informed consent and documentation. To schedule an in-person or virtual program, contact Matthew Lamb, Esq., at mlamb@mlmic.com or 518-786-2762.
MLMIC policyholders can reach our 24/7 emergency support services for questions regarding documentation or informed consent when treating the obstetrical patient by calling (844) MMS-LAW1. You can also submit a specific question by sending an email request here.
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